Infantile Subglottic Hemangioma: A Case ReportInfantile Subglottic Hemangioma: A Case Report.

ABSTRACT: Subglottic hemangiomas are rare benign vascular tumors of infancy which involve the airway. It is a subtype of infantile hemangiomas and is a potentially life-threatening condition with a mortality rate of 50% if left untreated. Hence, early intervention in this condition is essential. Here we present a case of a 4-month-old infant, a male infant with a history of cough and noisy breathing requiring multiple hospital visits before eventually being diagnosed with subglottic hemangioma. Due to its similar presentation with other more common respiratory illnesses, the diagnosis can be missed. Oral propranolol is the first-line therapy, which was used successfully in our case.

Comparison of Tracheal Intubation Using the Air-Q ILA and LMA Blockbuster Among Adults Undergoing Elective Surgery: A Randomized Controlled Trial.

Objective: Air-Q intubating laryngeal airway (ILA) is associated with a 58-77% success rate in blind intubation. The newer laryngeal mask airway (LMA) blockbuster is specially designed to facilitate easier endotracheal intubation and may have a higher success rate. The current study aimed to compare the success rate of endotracheal intubation using the Air-Q ILA and LMA blockbuster. Methods: After ethics committee approval and informed written consent, 140 adult patients with normal airways who were scheduled for elective surgery under general anaesthesia requiring endotracheal intubation were recruited for this randomized controlled trial. Blind endotracheal intubation was performed using the Air-Q ILA in group A and the LMA blockbuster in group B with special maneuvers and/or tubes in the second attempt. Fibreoptic bronchoscope (FOB) guidance was used in the third attempt if required. The primary outcome was the success rate of intubation without FOB assistance. The number of attempts for supraglottic airway (SGA) insertion, the time taken for SGA insertion, and the overall intubation time was also noted. Results: The success rate of intubation without FOB guidance was significantly higher in group B than in group A [91.4% vs 55.7%; relative risk (RR) 1.68; (95% confidence interval (CI) 1.34, 2.11); p<0.0001]. The number of attempts for SGA insertion was similar in groups A and group B [87% vs 90%; RR 1.03; (95% CI-0.92, 1.16); p=0.60]. The times for successful SGA insertion and endotracheal intubation were also similar between the groups. Conclusion: The LMA blockbuster offers a significantly higher success rate for endotracheal intubation without FOB guidance than the Air-Q ILA in adult patients with normal airways. However, an increased success rate was achieved with the use of a specially designed flexible endotracheal tube and maneuvers.

Pressure Distributions in Glottal Geometries With Multichannel Airflows.

OBJECTIVES: Computer simulation of self-sustained oscillation of the vocal folds has been successful with application of simple Bernoulli-like driving pressures. As voice simulation is now applied to asymmetric vibration with complex mode structures that yield partial vocal fold contact, the driving pressures need refinement. STUDY DESIGN AND METHODOLOGY: Two independent approaches were used to obtain pressure distributions. The first was a high-fidelity immersed-boundary method computation and the second was a series of pressure tap measurements on scaled-up physical models. Glottal geometries were based on normal surface modes of vibration. Samples are chosen from a large inventory of measured and calculated profiles. RESULTS: Pressure distributions show the complexity that can exist in the driving forces on vocal fold surfaces. Qualitative similarity between computation and measurement was established for a variety of contact patterns, showing diverse pressure gradients in multiple directions. CONCLUSIONS: Simplified Bernoulli approaches to glottal pressure distributions are defensible when a single flow channel is preserved in vocal fold oscillation. However, when there are contact islands that produce confluence or difluence of multiple airflow channels, the pressure gradients vary profoundly. Small quantitative differences were observed between measurement and calculation, primarily due to spatial sampling.

Cancer of the Larynx-20-Year Comparative Survival and Mortality Analysis by Age, Sex, Race, Stage, Grade, Cohort Entry Time-Period, Disease Duration and ICD-O-3 Topographic Primary Sites-Codes C32.0-9: A Systematic Review of 43,103 Cases for Diagnosis Years 1975-2017: (NCI SEER*Stat 8.3.9).

BACKGROUND: .-Laryngeal malignancy, "voice box" cancer, is uncommon with 12,620 estimated new cases and 3770 deaths in the United States in 2021,1 and represents only 6.2% of all respiratory system malignancies. The most significant risk factors are alcohol and tobacco consumption. Almost all cases (98%) of laryngeal cancer arise in the squamous epithelium, and in this analysis more than 75% are of well-or-moderately differentiated histopathology (Grades I&II). Local stage cancer (SEER Historic Staging) was more common than regional and distant stages combined (55.3% vs 44.7%). Tumors may arise above, below or at the level of the vocal folds and are described as supraglottic (encompassing the epiglottis, false vocal cords, ventricles, aryepiglottic fold and arytenoids), the glottis (encompassing the true vocal cords and the anterior and posterior commissures), and the subglottic region. In the National Cancer Institute's Surveillance, Epidemiology, End-Results (NCI-SEER) Data Research, 9 Registries, Nov 2019 Sub (1975-2017),2 laryngeal cancer occurred more commonly in men than in women, 80.7% vs 19.3%, respectively with a 4.2 to 1 ratio. Additionally, there are racial disparities with African Americans presenting at a younger age and having a higher incidence and mortality than Caucasians. In the 1975-2017 period, overall median patient age was 64.4 years with White Americans-64.8 years and Black Americans-61.5 years. Unfortunately, the 5-year relative survival rate has declined 4%, and excess death rate has risen 13% since 1975 with overall incidence declining.As a consequence, observed median survival is approximately 6.5-years for the total study-period pinpointing the need for further specialty research. This study follows the World Health Organization International Classification of Diseases for Oncology-3rd Edition (ICD-O-3)3 topographical identification, coding, labeling and listing of 43,103 patient-cases accessible for analysis in the United States National Cancer Institute's Surveillance, Epidemiology and End Results program (NCI SEER Research Data, 9 Registries, 1975-2017). These are located in 6 primary anatomical sites: C32.0-Glottis, C32.1-Supraglottis, C32.2-Subglottis, C32.3-Laryngeal cartilage, C32.8-Overlapping lesion of larynx, C32.9-Larynx, NOS. OBJECTIVES: .-To update short- and long-term mortality and survival indices, and identify changing risk patterns for laryngeal cancer patients in a retrospective US population-based analysis, 1975-2017, using prognostic data stratified by ICD-O-3 Primary Site, age, sex, race, stage, histologic grade, two cohort entry time-periods (1975-1996 to 1997-2017), and disease duration to 20-years. METHODS: .-SEER*Stat v8.3.94 software (built March 12, 2021) was used to access SEER Research Data, 9 Registries, Nov. 2019 submission (1975-2017). For displaying risk, general methods and standard double decrement life table methodologies for converting and displaying ICD-O-3 coded laryngeal cancer primary site annual data to aggregate average annual mortality and survival units in durational-intervals of 0-1, 1-2, 2-5, 0-5, 5-10, 10-15, and 15-20 years were employed. The reader is referred to the "Registrar Staging Assistant (SEER*RSA)" for local-regional-distant Extent of Disease (EOD) sources used in the development of staging descriptions, and Summary Stage 2018 Coding Manual v2.0 released September 1, 2020. Cancer staging & grading procedural explanations, statistical significance and 95% confidence levels5 are described in previous Journal of Insurance Medicine articles6,7 and other publications.8,9 Poisson confidence intervals at the 95% level based on the number of observed deaths are used in this study but not displayed here to conserve space on the mortality tables. Excluded were all death certificate only and those alive with no survival time. RESULTS: .-Total SEER annual age-adjusted incidence rates from 1980 to 2017 have diminished from 5.25 patient-cases/100,000/year to 2.59/100,000 per year, and in the same period annual age-adjusted US death rates declined from 1.61 deaths/100.000/year to 0.91 deaths/100,000/year (Ref. 10, CSR Tables 12.5-6), However, in the 0-5-year disease durational interval for all staged cases in both cohort time-periods (Table 5), excess death rates (EDR) rose from 80 per 1000 persons per year in the 1975-96 cohort, to 89 per 1000 persons per year in the 1997-17 cohort, (a 10% rise in excess mortality in 42 years). Further, in the 5-10-year disease durational interval, EDR rose from 39 per 1000 persons per year to 45 per 1000 persons per year with corresponding cohort declines in cumulative survival ratios (SR), and overall declines in median observed and relative survival times in the later cohort (not shown). The epidemiologic burden of malignancy is >4-fold higher in males and increases in parallel with aging, peaking after 65 years. The most significant risk factors for laryngeal cancer are tobacco and alcohol consumption. CONCLUSION: .-Although annual incidence and mortality rates from 1980 to 2017 have diminished, there is no concomitant improvement in larynx cancer survival (SR) and mortality (EDR) indices, with rising mortality and diminishing survival in all staged cases at 5-years disease duration between the 1975-96 and 1997-2017 analytic cohorts. Larynx cancer remains a burdensome clinical, social, and public health challenge.

Comparison between Air-Q Self Pressurized Airway Device with Blocker and Proseal Laryngeal Mask Airway in anesthetized paralyzed adult female patients undergoing elective gynecological operations.

INTRODUCTION: The Air-Q Self Pressurized Airway Device with Blocker (SP Blocker) was compared to the Proseal Laryngeal Mask Airway (PLMA) during positive pressure ventilation regarding the primary outcome (oropharyngeal leak pressure [OLP]), secondary outcomes (peak inspiratory pressure [PIP], inspired tidal volume [ITV], expired tidal volume [ETV], leak volume [LV] and leak fraction [LF]), insertion time, ventilation score, fiber-optic glottis view score, and postoperative laryngopharyngeal parameters (LPM). MATERIAL AND METHODS: Adult healthy female patients scheduled for elective gynecological laparotomies under general anesthesia using controlled mechanical ventilation were recruited to a prospective randomized comparative clinical trial. Exclusion criteria were body mass index (BMI) ≥ 35 kg m -2 , El-Ganzouri score ≥ 5, upper airway problems, hiatus hernia or pregnancy. Patients were classified into an SP Blocker group ( n = 75) and a PLMA group ( n = 75). Primary and secondary outcomes were assessed initially and at fixed time points after successful insertion of devices. RESULTS: Initially after successful device insertion: the SP Blocker group showed statistically significant higher mean OLP (cmH 2 O) (29.46 ± 2.11 vs. 28.06 ± 1.83 respectively; 95% CI: -2.037 to -0.76, P < 0.0001), lower mean PIP (cmH 2 O) (15.49 ± 0.61 vs. 17.78 ± 1.04 respectively; 95% CI: 2.02 to 2.56, P < 0.0001), higher mean ITV (mL) (411 ± 30 vs. 403 ± 15 respectively; 95% CI: -15.65 to -0.347, P = 0.041), higher mean ETV (mL) (389 ± 12 vs. 354 ± 11 respectively; 95% CI: -38.72 to -31.29, P < 0.0001), lower mean LV (mL) (22 ± 18 vs. 49 ± 10 respectively; 95% CI: 22.3 to 31.7, P < 0.0001) and lower mean LF (%) (5 ± 2.04 vs. 12 ± 6.8 respectively; 95% CI: 5.38 to 8.62, P < 0.0001) than the PLMA group. Mean insertion time (seconds) was shorter in the SP Blocker group than the PLMA group (16.39 ± 2.81 vs. 18.63 ± 3.44 respectively; 95% CI: 1.23 to 3.25, P < 0.0001). The SP Blocker group offered a better fiber-optic glottis view score than the PLMA group without differences concerning ventilation score and LPM. CONCLUSIONS: SP Blocker provided as safe anesthesia during controlled mechanical ventilation as PLMA.

Rare Glottic Pleomorphic Rhabdomyosarcoma: A Case Report with Review of Literature.

Rhabdomyosarcoma (RMS) is commonly reported in children and very rarely in adults. Laryngeal RMS is a rare but extremely aggressive malignancy with a high mortality rate. Surgery followed by postoperative radiotherapy is the preferred treatment. The use of chemotherapy is debatable. This report highlights a case of rare pleomorphic rhabdomyosarcoma of glottis in a 67-year-old male who presented with hoarseness and a description of its management.

Comparison of propofol versus dexmedetomidine sedation for awake C-MAC® D-Blade video laryngoscopic nasotracheal intubation in patients with difficult airway: A randomised clinical study.

Background and Aims: Awake intubation is the preferred method for securing difficult airways. We compared intravenous (IV) propofol and dexmedetomidine for C-MAC® D-blade-guided anticipated difficult nasotracheal intubation under conscious sedation. Methods: This randomised study included 60 patients with difficult airway (El-Ganzouri Score 4-9). After adequate airway preparation with IV midazolam 0.03 mg/kg and IV fentanyl 1 µg/kg, in Group P, propofol was infused at 250 µg/kg/min and in Group D, dexmedetomidine was infused at 1 µg/kg over 10 min, then at 0.5 µg/kg/h till a bispectral index (BIS) value 65-70 was achieved. Patients underwent C-MAC® D-blade video laryngoscope-guided nasotracheal intubation. The intubation score was the primary outcome measure. Secondary outcome measures included haemodynamic parameters, intubation time, number of attempts, the incidence of failed awake intubation, glottic view, time to achieve desired BIS, complications, study drug consumption and patient-reported satisfaction with the awake intubation technique. Quantitative variables were compared between groups using unpaired t-test/Welsch test/Mann-Whitney Test. Qualitative variables were correlated using the Chi-square test/Fisher's exact test. A P value of <0.05 was considered statistically significant. Results: The intubation score was significantly higher in Group D versus Group P (P = 0.007). Patient reaction to intubation, haemodynamic parameters and percentage of glottis opening score were more favourable in Group P. Coughing and vocal cord movement were comparable between the groups (P > 0.05). The time to target BIS was four times longer, and the time to intubate was 6 seconds longer in Group D. Conclusion: Successful awake C-MAC® D-blade video laryngoscopic intubation can be performed under dexmedetomidine/propofol conscious sedation, with propofol giving a better intubation score.

Assessing respiratory airflow unsteadiness under different tidal respiratory frequencies using large eddy simulation method.

Unsteady respiratory airflow characteristics play a crucial role in understanding the deposition of toxic particles and inhaled aerosol drugs in the human respiratory tract. Considering the variations in respiratory flow rate and glottis motion under different respiratory frequencies, these respiratory airflow characteristics are studied by large-eddy simulations, including pressure field, power loss, modal spatial patterns, and vortex structures. Firstly, the results reveal that varying respiratory frequencies significantly affect airflow unsteadiness, turbulent evolution, and vortex structure dissipation, as they increase the complexity and butterfly effect introduced by the turbulent disturbance. Secondly, the pressure drops and flow rate at the glottis also conform to a power-law relationship considering the respiratory physiological characteristics, especially under low respiratory frequencies. Glottis motion plays different roles in energy consumption during inspiration and expiration, and its magnitude can be predicted using a polynomial function based on glottis area and respiratory flowrate under different respiratory frequencies. Finally, modal decomposition can be effectively applied to the study of respiratory flow characteristics, but we recommend separately studying the inspiration and expiration. The spatial distribution of the dominant mode characterizes the majority of respiratory flow characteristics and are influenced by respiratory frequency. Spectral entropy results indicate that glottis motion and slow breathing both delay the transitions in the upper respiratory tract during inspiration and expiration. These results confirm that the respiratory physiology characteristics under different respiratory frequencies have a significant impact on the unsteady respiratory airflow characteristics and warrant further study.

To compare the efficacy of the between-the-fingers grip with the conventional pen-holding grip to hold an endotracheal tube for orotracheal intubation: A randomised controlled trial.

Background and Aims: Correctly holding the endotracheal tube (ETT) is essential for successful tracheal intubation. The study's primary objective was to compare the between-the-fingers grip with the conventional pen-holding grip regarding the number of attempts required for orotracheal intubation and usage of external aids. Methods: Three hundred patients undergoing elective surgeries under general anaesthesia were randomised according to the method to hold the ETT to Group C (conventional grip) and Group M (modified, between-the-fingers grip) during oro-tracheal intubation. A designated anaesthetist blinded to the groups performed laryngoscopy in all the patients, and difficult Cormack-Lehane grade 3b and 4 (n = 24) were excluded. Then, the group was revealed to the anaesthetist, and intubation was done accordingly; the number of attempts, use of backward upward rightward pressure (BURP), and time taken were noted. The sample size was estimated using the software G*Power version 3.1.9.2. Statistical Package for Social Sciences, version 23 (SPSS-23, IBM, Chicago, USA) was used for data analysis. Results: Single-attempt intubation was comparable between the groups (99.3% versus 97.2%, P = 0.197). In contrast, the external assistance as BURP (0.75% versus 6.99%, P = 0.009) and the time taken for intubation (P = 0.008) were reduced in group M significantly. Conclusion: The between-the-fingers grip seems as effective as the standard grip to hold the ETT during intubation. However, it proved to be better as it can reduce the requirement for external assistance in BURP.

Deep Learning-Based Detection of Glottis Segmentation Failures.

Medical image segmentation is crucial for clinical applications, but challenges persist due to noise and variability. In particular, accurate glottis segmentation from high-speed videos is vital for voice research and diagnostics. Manual searching for failed segmentations is labor-intensive, prompting interest in automated methods. This paper proposes the first deep learning approach for detecting faulty glottis segmentations. For this purpose, faulty segmentations are generated by applying both a poorly performing neural network and perturbation procedures to three public datasets. Heavy data augmentations are added to the input until the neural network's performance decreases to the desired mean intersection over union (IoU). Likewise, the perturbation procedure involves a series of image transformations to the original ground truth segmentations in a randomized manner. These data are then used to train a ResNet18 neural network with custom loss functions to predict the IoU scores of faulty segmentations. This value is then thresholded with a fixed IoU of 0.6 for classification, thereby achieving 88.27% classification accuracy with 91.54% specificity. Experimental results demonstrate the effectiveness of the presented approach. Contributions include: (i) a knowledge-driven perturbation procedure, (ii) a deep learning framework for scoring and detecting faulty glottis segmentations, and (iii) an evaluation of custom loss functions.

A Comparison of Miller Straight Blade and Macintosh Blade Laryngoscopes for Intubation in Morbidly Obese Patients.

The primary objective of this study was to demonstrate whether the Miller blade laryngoscope could provide better visualization of the vocal cords in morbidly obese patients than the Macintosh blade laryngoscope. The secondary objective was to identify the patient-measured factors associated with better visualization of the vocal cords when using the Miller vs. Macintosh blade, as well as whether the application of external pressure might improve the visibility of the glottis during intubation. A prospective, observational study encompassing 110 patients with a BMI > 40 undergoing elective bariatric surgery and intubation procedure was performed. The evaluation of the vocal cords was performed according to the Cormack-Lehane scale and POGO scale in the same patient during intubation, performed with a Miller and a Macintosh blade laryngoscope, in a random matter. The following parameters were assessed: body weight, height, BMI, neck circumference, thyromental distance, sternomental distance, mouth opening, and Mallampati scale and their impact on visualization of the vocal cords using the Miller blade without the application of external pressure. The Miller blade provides an improved view of the glottis compared to the Macintosh blade measured with both the Cormac-Lehane scale (45 (40.91%) without external pressure application on the larynx, and 18 (16.36%) with external pressure application on the larynx) and the POGO scale (45 (40.91%) without external pressure application on the larynx, and 19 (17.27%) with external pressure application on the larynx). The application of laryngeal pressure improved the view of the glottis. Among the measured features, a significant improvement in the visibility of the glottis could be found in patients with a BMI over 44.244 kg/m2 and a neck circumference over 46 cm. To conclude, the usage of the Miller blade improves the visibility of the glottis compared to the Macintosh blade in morbidly obese patients. The recommendation to use the Miller blade in this group of patients requires further investigation, taking into account the effectiveness of the intubation. Trial Registration: NCT05494463.

Scale resolving simulations of the effect of glottis motion and the laryngeal jet on flow dynamics during respiration.

BACKGROUND AND OBJECTIVE: The movement of the respiratory walls has a significant impact on airflow through the respiratory tract. The majority of computational fluid dynamics (CFD) studies assume a static geometry which may not provide a realistic flow field. Furthermore, many studies use Reynolds Averaged Navier-Stokes (RANS) turbulence models that do not resolve turbulence structure. Combining the application of advanced scale-resolving turbulence models with moving respiratory walls using CFD will provide detailed insights into respiratory flow structures. METHODS: This study simulated a complete breathing cycle involving inhalation and exhalation in a nasal cavity to trachea geometry that incorporated moving glottis walls. A second breathing cycle was simulated with static glottis walls for comparison. A recently developed hybrid RANS-LES turbulence model, the Stress-Blended Eddy Simulation (SBES), was incorporated to resolve turbulent flow structures in fine detail for both transient simulations. Transient results were compared with steady-state RANS simulations for the same respiratory geometry. RESULTS: Glottis motion caused substantial effects on flow structure through the complete breathing cycle. Significant flow structure and velocity variations were observed due to glottal motion, primarily in the larynx and trachea. Resolved turbulence structures using SBES showed an intense mixing section in the glottis region during inhalation and in the nasopharynx during expiration, which was not present in the RANS simulations. CONCLUSION: Transient simulations of a realistic breathing cycle uncovered flow structures absent in simulations with a constant flow rate. Furthermore, the incorporation of glottis motion impacted airflow characteristics that suggest rigid respiratory walls do not accurately describe respiratory flow. Future research in respiratory airflow should be conducted using transient scale-resolving models in conjunction with moving respiratory walls to capture flow structures in detail.

Clinical and Anatomical Variation During Assessment of Maximum Glottic Angle.

INTRODUCTION: Quantitative measurement and analysis of glottic abduction is used to assess laryngeal function and success of interventions; however, the consistency of measurement over time has not been established. This study assesses the consistency of glottic abduction measurements across visits in healthy patients and anatomic factors impacting these measurements. METHODS: Review of patients with two sequential flexible stroboscopic exams over seven months from 2019-2022. Images of maximal glottic abduction were captured and uploaded into and measured with ImageJ. Cadaver heads were used to assess the impact of visualization angles on glottic measurements with a monofilament inserted into the supraglottis of each cadaver as a point of reference. Comparisons were done with a paired T-test, T-test, or Mann-Whitney U test as appropriate. RESULTS: Fifty-nine patients and twenty-six cadaveric exams were included. Absolute change in maximum glottic abduction angle (MGAA) was 6.90° (95% CI [5.36°, 8.42°]; p < 0.05). There were no significant differences in change in MGAA by gender or age. Twenty percent of patients had a change of at least 25% in their MGAA between visits. Absolute differences in glottic angle between nasal side for cadaveric measurements was 4.77 ± 4.59° (p < 0.005)-2.22° less than the change in MGAA seen over time (p = 0.185). CONCLUSION: Maximal glottic abduction angles varied significantly between visits. Factors considered to be contributing to the differences include different viewing windows between examinations due to the position and angulation of the laryngoscope and changes in patient positioning, intra- and inter-rater variations in measurement, and patient effort. LEVEL OF EVIDENCE: N/a Laryngoscope, 134:2793-2798, 2024.

[Update on manual bronchial clearance techniques (adults and adolescents)]. / Mise au point sur les techniques manuelles de désencombrement bronchique (adultes et adolescents).

In adults and teenagers, airway clearance physiotherapy techniques (ACPT) are various and numerous. However, they for still awaiting scientific validation. Among ACPTs, Slow Expiration with the Glottis Opened in the Lateral Posture (ELTGOL), Autogenic Drainage (DA), and Active Cycling Breathing Technique (ACBT) present a Grade B level of evidence with weak recommendations. Even though these maneuvers are widely applied, precise description of chest physiotherapy (CP) is largely absent from the scientific literature; it is difficult to standardize its implementation and reproduce the results; scientific validation and faithful execution of the techniques are consequently problematic. In this paper, the authors aim to depict each of the three CP techniques as precisely as possible; with this in mind, graphic modeling of the different respiratory exercises is presented in such a way that they can be easily learned, applied and reproduced by physiotherapists.

Accelerated three-dimensional conformal radiotherapy for early-stage glottic cancer in reducing dose to the internal carotid artery and pharyngeal constrictor muscles.

BACKGROUND: We evaluated clinical and dosimetric outcomes of radiotherapy using two anterior oblique portals (AOP), to reduce the dose to the bilateral internal carotid arteries (CAs) and pharyngeal constrictor muscle (PCM) during early-stage glottic cancer (ESGC) treatment. METHODS: We identified patients with ESGC who underwent definitive radiotherapy between June 2014 and May 2020. RESULTS: Among the 66 patients, 32 (48%) underwent radiotherapy using AOP, and the remaining underwent typical radiotherapy using parallel opposed lateral portals (POLP). The median follow-up duration was 53 months. No significant differences were observed in the 5-year local failure (0%/9.4%), progression-free survival (90.6%/90.8%), and overall survival (90.6%/91.0%) rates between the two groups. The grade ≥2 acute mucositis incidence rate was significantly lower in the AOP group (44%/85%). Radiotherapy using AOP maintained an adequate dose coverage to the target while markedly reducing the CAs and PCM doses. CONCLUSION: Radiotherapy with AOP resulted in favorable clinical and dosimetric outcomes.

Closed- or open-glottis pushing for vaginal delivery: a planned secondary analysis of the TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery study.

BACKGROUND: The effect on obstetrical outcomes of closed- or open-glottis pushing is uncertain among both nulliparous and parous women. OBJECTIVE: This study aimed to assess the association between open- or closed-glottis pushing and mode of delivery after an attempted singleton vaginal birth at or near term. STUDY DESIGN: This was an ancillary planned cohort study of the TRAAP (TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery) randomized controlled trial, conducted in 15 French maternity units from 2015 to 2016 that enrolled women with an attempted singleton vaginal delivery after 35 weeks' gestation. After randomization, characteristics of labor and delivery were prospectively collected, with special attention to active second-stage pushing and a specific planned questionnaire completed immediately after birth by the attending care provider. The exposure was the mode of pushing, classified into 2 groups: closed- or open-glottis. The main endpoint was operative vaginal delivery. Secondary endpoints were items of maternal morbidity, including severe perineal laceration, episiotomy, postpartum hemorrhage, duration of the second stage of labor, and a composite severe neonatal morbidity outcome. We also assessed immediate maternal satisfaction, experience of delivery, and psychological status 2 months after delivery. The associations between mode of pushing and outcome were analyzed by multivariate logistic regression to control for confounding bias, with multilevel mixed-effects analysis, and a random intercept for center. RESULTS: Among 3041 women included in our main analysis, 2463 (81.0%) used closed-glottis pushing and 578 (19.0%) open-glottis pushing; their respective operative vaginal delivery rates were 19.1% (n=471; 95% confidence interval, 17.6-20.7) and 12.5% (n=72; 95% confidence interval, 9.9-15.4; P<.001). In an analysis stratified according to parity and after controlling for available confounders, the rate of operative vaginal delivery did not differ between the groups among nulliparous women: 28.7% (n=399) for the closed-glottis and 27.5% (n=64) for the open-glottis group (adjusted odds ratio, 0.93; 95% confidence interval, 0.65-1.33; P=.7). The operative vaginal delivery rate was significantly lower for women using open- compared with closed-glottis pushing in the parous population: 2.3% (n=8) for the open- and 6.7% (n=72) for the closed-glottis groups (adjusted odds ratio, 0.43; 95% confidence interval, 0.19-0.90; P=.03). Other maternal and neonatal outcomes did not differ between the 2 modes of pushing among either the nulliparous or parous groups. CONCLUSION: Among nulliparous women with singleton pregnancies at term, the risk of operative vaginal birth did not differ according to mode of pushing. These results will inform shared decision-making about the mode of pushing during the second stage of labor.

Effects of vocal fold lesions on particle deposition in a mouth-throat model: A numerical study.

OBJECTIVE: Dysphonia is very common worldwide and aerosol drug inhalation is an important treatment for patients with dysphonia. This study aimed to explore the effects of vocal fold (VF) lesions on the particle deposition pattern using computational modeling. METHODS: A realistic mouth-throat (MT) model of a healthy adult was constructed based on computed tomography images. Small and large vocal fold lesions were incorporated in the original model. A steady inhalation flowrate of 15 and 30 liter per minute (LPM) was used as the velocity inlet and monodisperse particles with diameters of 5 to 10 µm were simulated. RESULTS: Particles of larger size are more likely to be deposited in MT models, most of them distributed in oral cavity, oropharynx and supraglottis. The ideal sizes at 30 LPM ranged over 7-10 µm for healthy VFs and 6-8 µm for VF lesions. The best sizes at 15 LPM ranged over 6-8 µm for healthy VFs and 8-9 µm for VF lesions. CONCLUSION: Based on this study, VF lesions influence the deposition pattern in the glottis obviously. The ideal sizes differ at the flow rates of 15 and 30 LPM.

Outcome of radiotherapy for the treatment of laryngeal squamous cell carcinoma in the very elderly population.

BACKGROUND: Treatment selection for squamous cell carcinoma patients aged over 84 years is controversial. This retrospective chart review examined and compared characteristics of laryngeal squamous cell carcinoma in very elderly (over 84 years) and younger patients (approximately 65 years). The secondary objective was to further evaluate the outcome of radiotherapy as a treatment modality in this patient population. METHODS: Of all 23 very elderly patients with laryngeal squamous cell carcinoma treated with radiotherapy, with or without surgery, in the Davidoff Cancer Center, from 1992 to 2012, 19 had sufficient data for analysis, and comprised the study group. RESULTS: Median age at diagnosis was 86 years. Disease stage at diagnosis was I, II, III and IVA in 53 per cent, 21 per cent, 21 per cent and 5 per cent, respectively. Median radiotherapy dose was 60 Gy given in 25 fractions. Three patients had recurrence. No patient discontinued treatment because of toxicity. Median overall survival was 3.6 years (range, 0-10 years). CONCLUSION: Very elderly laryngeal squamous cell carcinoma patients may derive a similar survival advantage as younger counterparts. Modern radiotherapy is effective and safe for treating laryngeal squamous cell carcinoma in this study population. Further, large-scale studies are needed.

The neonatal airway.

Safe and effective management of the neonatal airway requires knowledge, teamwork, preparation and experience. At baseline, the neonatal airway can present significant challenges to experienced neonatologists and paediatric anaesthesiologists, and increased difficulty can be due to anatomical abnormalities, physiological instability or increased situational stress. Neonatal airway obstruction is under recognised, and should be considered an emergency until the diagnosis and physiological implications are understood. When multiple types of difficulties are present or there are multiple levels of anatomical obstruction, the challenge increases exponentially. In these situations, preparation, multi-disciplinary teamwork and a consistent hospital-wide approach will help to reduce errors and morbidity.

Comparative evaluation of C-MAC and McGrath MAC videolaryngoscopes with Macintosh direct laryngoscope for endotracheal intubation in adult patients undergoing elective surgeries.

Background and Aims: Videolaryngoscopes have an undisputed role in difficult airway management, but their role in routine intubation scenarios remains underappreciated. McGrath MAC is a lightweight laryngoscope with a disposable blade. It remains to be proven if it performs as efficiently as the reusable videolaryngoscopes like C-MAC and whether it has an advantage over standard Macintosh laryngoscope in predicted normal airways. Material and Methods: We recruited 180 adult patients and randomly divided them into three groups for intubation with either Macintosh laryngoscope (Group-A), C-MAC (Group-B), and McGrath (Group-C). The primary objective was to compare the first attempt success rate. Secondary objectives included Cormack-Lehane (CL) grades, laryngoscopy time, intubation time, ease of intubation, need for optimization manoeuver, and the number of passes to place the endotracheal tube. Results: The two videolaryngoscopes provided a superior first attempt success rate as compared to Macintosh laryngoscope (P = 0.027). The CL grade-I was 100% in group B, 41.7% in group-A and 90% in group-C (B vs C; P = 0.037). Laryngoscopy time was 9.9 ± 2.5 s, 12.6 ± 0.8 s, and 13.1 ± 0.8 s for groups A, B, and C, respectively (B vs C; P = 0.001). Intubation time was 24.4 ± 12 s, 28.3 ± 1.9 s, and 37.3 ± 5.8 s for groups A, B, and C, respectively (P < 0.0001). The number of tube passes was highest in group C. Conclusion: Videolaryngoscopes provided a superior glottic view and resulted in a superior first attempt success rate as compared to Macintosh laryngoscope. When comparing the two videolaryngoscopes, C-MAC resulted in better intubation characteristics (shorter intubation time, better glottic views, and higher first-attempt success rates) and should be preferred over McGrath for intubation in adult patients with normal airways.