Search Results (55)

Background/Objectives: This study aimed to compare glottic visualization and intubation performance during laryngoscopy with the C-MAC video laryngoscope size 1 Miller blade using direct epiglottic elevation versus vallecular placement of the blade tip in children younger than 2 years of age. Methods: This prospective, randomized controlled trial enrolled 127 ASA physical status I–II children younger than 2 years undergoing elective surgery. Participants were randomly allocated to Group V (vallecular placement; n = 62) or Group E (direct epiglottic elevation; n = 65). Anesthesia was induced with fentanyl, thiopental, sevoflurane, and rocuronium. The Percentage of Glottic Opening (POGO) score, Cormack–Lehane grade, Intubation Difficulty Score (IDS), Visual Analogue Scale (VAS) score, laryngoscopy and intubation times, intubation attempts, optimization maneuvers, and complications were recorded. Results: The POGO score was significantly higher in Group E (median [IQR], 96 [92–100]) than in Group V (95 [88–100]; p = 0.032). Cormack–Lehane grades were significantly better in Group E than in Group V (p = 0.042). Laryngoscopy time was significantly shorter in Group V (5.61 ± 1.15 s) than in Group E (6.95 ± 1.80 s; p = 0.001). Intubation time was also significantly shorter in Group V (23.16 ± 4.44 s) than in Group E (26.60 ± 4.73 s; p = 0.001). VAS scores were significantly higher in Group V (9.48 ± 1.09) than in Group E (9.02 ± 1.09; p = 0.018). Conclusions: Direct epiglottic elevation with the C-MAC video laryngoscope size 1 Miller blade improved glottic visualization, whereas vallecular placement was associated with shorter laryngoscopy and intubation times in children younger than 2 years. The choice between the two techniques may depend on clinical priorities; vallecular placement may be considered when minimizing intubation time is a priority, although this hypothesis requires prospective evaluation in higher-risk populations. Full article

Background/Objectives: Video laryngoscopy improves the glottic view, yet difficult intubation still occurs. Whether it reflects a poor view or arises despite an adequate one is rarely quantified in otorhinolaryngological surgery. We described this pattern and its preoperative predictors. Methods: In a single-center retrospective cohort of 1932 adults undergoing otorhinolaryngological surgery with non-channeled video laryngoscopy (2018–2021), difficult intubation was defined a priori as two or more laryngoscopic attempts (blade insertions), a lower bound on difficulty. The glottic view (Cormack–Lehane grade) and intubation time described the difficulty, and predictors were identified by logistic regression. An unweighted count of four anatomical bedside factors, selected on rationale (not data-driven significance) at pre-existing clinical thresholds, was the primary risk score; a five-factor version added a resident operator. Results: Difficult intubation occurred in 120 patients (6.2%; 95% CI 5.2–7.4). Most occurred despite an adequate view (64% at Cormack–Lehane grade I–II; 45% at grade I alone); the rate was 4.3% (95% CI 3.5–5.4) versus 29.3% (95% CI 22.5–37.1) for good versus poor views (odds ratio 9.2, 95% CI 6.0–14.0), and difficult intubations took about twice as long (median 90 versus 40 s). Independent predictors were shorter inter-incisor and thyromental distances and a resident operator. The four-factor count graded risk from 4.6% to 12.9% (odds ratio 1.63 per factor; apparent area under the curve 0.596, 95% CI 0.546–0.645, not corrected for optimism; positive predictive value 8.8% at one or more factors), and a five-factor count performed similarly (0.631). Within the good-view subgroup, difficulty appeared to relate more to operator inexperience than to anatomy (adjusted odds ratio 2.48 versus 1.13). Conclusions: Difficulty was far more likely with a poor view, but because a good view occurred in 92.4% of patients, most difficult intubations arose despite an adequate one. We hypothesize that difficulty then lies in tube delivery rather than visualization; because the analysis conditions on the view, this needs prospective testing. Discrimination was modest and the count exploratory; these single-center findings require external validation. Full article

Background and Clinical Significance: Anti–myelin-associated glycoprotein (MAG) antibody polyneuropathy is a rare, chronic IgM-mediated demyelinating peripheral neuropathy predominantly affecting sensory nerves in older adults, commonly in association with monoclonal gammopathy of undetermined significance. Reports describing anesthetic management in patients with this condition remain extremely limited, and no specific guidelines currently exist regarding neuromuscular blocking agent (NMBA) use or neuromuscular monitoring in this population. Case Presentation: A 79-year-old man with anti-MAG antibody polyneuropathy (diagnosed in 2007) and IgM monoclonal gammopathy of undetermined significance developed disproportionate progressive lower-extremity weakness and became wheelchair-dependent following COVID-19 infection in 2020. Preoperative evaluation revealed mildly reduced left ventricular function (ejection fraction 49%), mild chronic kidney disease, and marked intrinsic hand muscle atrophy with absent deep tendon reflexes. He was scheduled for robot-assisted radical cystectomy with ileal conduit diversion under combined general and thoracic epidural anesthesia. Before NMBA administration, neuromuscular monitoring was systematically attempted at the ulnar nerve (electromyography and acceleromyography, up to 60 mA/300 μs) and the corrugator supercilii; despite visible muscle contractions following peripheral nerve stimulation, neither modality produced reliable responses at either site. Given the inability to establish reliable monitoring, the administration of NMBAs was considered to carry an unacceptable risk of a prolonged, undetectable blockade. Anesthesia was maintained with deep sevoflurane (2.0–2.5% end-tidal) and remifentanil infusion without NMBAs, titrated to a bispectral index of 40–60. Tracheal intubation was accomplished via video laryngoscopy without NMBA. The 7 h and 30 min surgery was completed without patient movement or surgical compromise. Postoperatively, the patient developed transient upper airway obstruction attributed to glossoptosis, managed successfully with head elevation and nasopharyngeal airway insertion; supplemental oxygen was required until postoperative day 3, and the patient was discharged from the high-dependency unit on postoperative day 5. Conclusions: No measurable quantitative neuromuscular response could be obtained in this patient with advanced anti-MAG antibody neuropathy, despite appropriate application of electromyography- and acceleromyography-based monitoring and the presence of visible muscle contractions following peripheral nerve stimulation. In such circumstances, avoiding NMBA administration in favor of deep volatile or intravenous anesthesia with opioid supplementation may represent a reasonable, hypothesis-generating approach in carefully selected patients; this observation does not establish the general superiority of an NMBA-free strategy, and caution is warranted before generalizing it to procedures such as robotic surgery, in which profound neuromuscular blockade is often considered desirable. Full article

Background/Objectives: Unanticipated difficult airway remains a critical patient safety concern in perioperative care. Despite routine preoperative assessment, difficult intubation may still occur in patients without obvious high-risk findings. This study aimed to evaluate perioperative factors associated with unanticipated difficult intubation and to examine the relationship between preoperative assessment and intraoperative intubation difficulty in routine clinical practice. Methods: This retrospective case–control study included adult patients undergoing general anesthesia with tracheal intubation between 2015 and 2020 at a tertiary care hospital. Unanticipated difficult intubation was defined as requiring ≥3 intubation attempts without documented preoperative suspicion of difficult airway. Patients with anticipated difficult airway or preoperative mechanical ventilation were excluded. A total of 95 cases and 429 controls were analyzed. Associations were explored using multivariable logistic regression. Results: Among 524 patients, cases more frequently had ASA physical status III and airway/neck/oral deformity. Notably, intubation difficulty became evident only at laryngoscopy, characterized by poorer visualization, increased intubation attempts (median 4 vs. 1), and frequent escalation to video laryngoscopy. Severe laryngoscopic views (Cormack–Lehane grade III–IV: 74.8% vs. 3.0%) were markedly overrepresented among cases. In multivariable analysis, ASA III and airway deformity remained independently associated with unanticipated difficult intubation. The model demonstrated modest discrimination (AUC 0.685). Conclusions: Unanticipated difficult intubation was uncommon but clinically important and frequently became apparent only during airway management. Although several associated factors were identified, routine bedside airway assessment alone may not reliably predict all cases of intraoperative difficult intubation. These findings highlight the limitations of routine bedside airway assessment in identifying all patients who subsequently experience difficult intubation and support the need for improved strategies to identify patients at risk. Full article

Background/Objectives: Surfactant has been delivered via less-invasive surfactant administration (LISA) in our neonatal intensive care unit (NICU) since 2020. Data have been monitored and the literature regularly reviewed to improve our LISA practice. The purpose of this project is to share the clinical practice changes made to help other NICU providers fine-tune their LISA practice. Methods: The original LISA criteria included babies with GA 27–36 6/7 w, on > 21% O₂, on continuous positive airway pressure (CPAP), pCO₂ < 70 if a blood gas was obtained, and radiographic and/or clinical evidence of respiratory distress syndrome (RDS). Current criteria include GA 25–35 6/7 w and minimum CPAP + 6. This manuscript highlights the changes made since 2023. To monitor these changes, targeted data from the entire cohort were examined before and after each change. Results: LISA was attempted on 399 babies (average (SD) GA 31.7 (2.7), birth weight 1752 (590), with a procedural success rate of 97%. Overall, 18% required intubation within 7 days after LISA. The median (IQR) for FiO₂ was 32 (28, 40) prior to LISA and 23 (21, 30) post-LISA and the hour of age of LISA was 4 (2.5, 9.9). LISA procedure success rate was increased by the use of video laryngoscopy as well as reinforcement of the use of sucrose sedation and swaddling; our first attempt success increased overall from 39% to 52%. After the introduction of a clinical RDS score (Downes), there was an expected and logical increase in the number of infants requiring intubation within 7 days of LISA indicating likely over-treatment prior to this change. After implementation of a clearly described plan for babies <28 w gestation there was a decrease in the hour of age of LISA from 3 (2.5, 4.5) to 2 (0.8, 3) h. Conclusions: It is critical to continually evaluate a new practice and identify strategic changes. We offer our changes to assist others starting or using LISA. Full article

Accurate and rapid detection of anatomical structures, such as the glottis, is critical during tracheal intubation (TI) to ensure patient safety and procedural success. However, it remains a challenge due to the limited field of view and computational resources of video laryngoscopy, especially for difficult airway situations. Existing deep learning (DL) models struggle to balance high accuracy and real-time clinical deployment. To address these issues, we propose TI-YOLO (TI-You Only Look Once), a lightweight and efficient object detection model built upon the YOLOv11 architecture. TI-YOLO introduces the Bidirectional Feature Pyramid Network (BiFPN) module for multi-scale feature fusion, effectively enhancing the ability to detect anatomical structures of different sizes. TI-YOLO integrates the Deformable Attention Transformer (DAT) module to enhance the perception of crucial regions, improving detection accuracy and robustness. To further reduce the consumption of computational resources while maintaining efficiency, TI-YOLO is optimized by reconstructing the backbone based on MobileNetV4. Furthermore, TI-YOLO employs the Slide Weight Function (SWF) as a loss function during model training to mitigate the class imbalance within the dataset. One self-built dataset is used to validate the effectiveness of TI-YOLO. Compared to the original YOLOv11, TI-YOLO achieves mean Average Precision at IoU 0.50 (mAP50) scores of 0.902, with improvements of 3.8%. Meanwhile, TI-YOLO balances detection accuracy and computational efficiency with a 10.5% reduction in floating-point operations (FLOPs) and a 28.9% reduction in parameters, and the model weight is only 4.6 MB. Additionally, to evaluate TI-YOLO real-time inference capability, we quantize and deploy it on a low-cost embedded OrangePi 5 platform. The inference speed reaches over 50 frames per second (FPS), meeting real-time clinical requirements. Full article

Background: Arytenoid cartilage dislocation (ACD) is a rare but clinically significant complication of endotracheal intubation that may be misdiagnosed as transient vocal cord paralysis. The potential role of prolonged surgical positioning in ACD remains underrecognized. Methods: A 63-year-old male developed left posterior ACD following robot-assisted radical prostatectomy (RARP) performed in a steep Trendelenburg position for 3.5 h. Intubation was successfully achieved on the first attempt using a video laryngoscope with full glottic visualization and no apparent airway trauma. Postoperatively, the patient developed persistent dysphonia, dysphagia, aspiration, and tongue deviation. Initial flexible laryngoscopy suggested left vocal cord paralysis, whereas direct laryngoscopy on postoperative day 6 confirmed posterior arytenoid dislocation. Urgent closed reduction was performed, followed by structured voice therapy, which resulted in substantial functional recovery. Discussion: This case illustrates that ACD may occur despite technically optimal and atraumatic intubation and should be interpreted as reflecting a temporal association rather than a definitive causal relationship. Prolonged steep Trendelenburg positioning and extended operative duration may be considered potential contributing biomechanical factors, possibly mediated by venous congestion, mucosal edema, altered endotracheal tube dynamics, and cumulative shear stress on the cricoarytenoid joint. However, these mechanisms remain interpretive and hypothesis-generating. Conclusions: Prolonged steep Trendelenburg positioning and extended operative duration may represent possible contributing biomechanical factors in ACD, even in the setting of atraumatic intubation. Early laryngeal evaluation and timely reduction remain essential for optimal functional recovery. Full article

Airway management is central to the care of critically ill patients, yet it remains one of the most challenging interventions in emergency departments and intensive care units. Patients often present with severe physiological instability, limited cardiopulmonary reserve, and high acuity, while clinicians often work under constraints related to time for preparation, equipment availability, trained workforce, monitoring, and access to advanced rescue techniques. These challenges are particularly pronounced in low- and middle-income countries and other resource-limited or austere environments, where the margin for error is narrow and delays or repeated attempts in airway management may rapidly precipitate hypoxemia, hemodynamic collapse, or cardiac arrest. Although contemporary airway guidelines emphasize structured preparation and rescue pathways, many assume resources that are not consistently available in such settings. This narrative review discusses pragmatic, context-adapted strategies for airway management in constrained environments, with emphasis on physiology-first preparation, appropriate oxygenation and induction techniques, simplified rapid-sequence intubation, and the judicious use of basic airway adjuncts, supraglottic devices, and video laryngoscopy, where available. Adapted difficult airway algorithms, front-of-neck access in the absence of surgical backup, human factors, team training, and ethical considerations are also addressed. This review aims to support safer and effective airway management for critically ill patients in resource-limited emergency and intensive care settings. Full article

Background/Objectives: Studies have demonstrated significant morbidity and mortality associated with airway management, especially when provided outside of the operative setting. The goal of this study was to compare baseline measurements of airway management procedures between anesthesia providers (CRNAs and anesthesiologists) and respiratory therapists using high-fidelity manikins. Methods: This prospective study assessed anesthesia providers and respiratory therapists performing direct laryngoscopy (DL), video laryngoscopy (VL), and LMA placement. The same Laerdal SimMan high-fidelity manikin (Laerdal, Stavanger, Norway) was used in all assessments, with the detection of end-tidal “carbon dioxide” serving as evidence of success for each procedure. Each procedure was performed twice, once under “Healthy Patient” SimMan settings, and once under the “Limited Cervical Range of Motion (ROM)” (DL), “Pharyngeal Obstruction” (VL), and “Full Tongue Edema” (LMA) settings, respectively, to simulate a moderately difficult airway. The order in which the techniques were performed was randomized for each participant. Completion time and number of attempts were recorded for each procedure and compared between the groups. Results: Sixty-two providers (30 anesthesia providers and 32 respiratory therapists) were enrolled. There were no significant differences in average time to completion for any procedure, except respiratory therapists took longer than anesthesia providers in VL with simulated pharyngeal obstruction (p = 0.0004). There were no differences in number of attempts needed for successful completion. Conclusions: This study demonstrates that while completion times for DL and LMA placement were similar amongst provider groups, average time to completion of VL for respiratory therapists was longer under difficult simulated settings. These results reflect potential areas of improvement for other provider groups that may have airway privileges at their respective institutions. Full article

Nasotracheal Intubation (NTI) is a common route of airway management in many situations. Over the years, numerous techniques and approaches have been described in performing NTI safely and effectively, including many innovative techniques being published in recent years. However, there hasn’t been a summary of the recent approaches to NTI, especially in an easy, clinically applicable decision making format. In fact, the last algorithmic approach to nasal intubation in the literature was published in 2008. This comprehensive review details an updated analysis of NTI techniques along with a new adapted algorithmic outline to approach NTI in a methodical and stepwise manner. There is also an extensive review of techniques to control epistaxis, which is the most commonly encountered complication during NTI. The newly adapted NTI algorithm simplifies the initial approach to three options: Routine Asleep NTI, Awake NTI, and an Initial Orotracheal Intubation (OTI) followed by Conversion to NTI. Older techniques, such as blind NTI, flexible intubation scope guided, “look before you leap” approach and cuff inflation technique, are discussed along with incorporation of newer techniques, such as videolaryngoscope guided, hybrid, alignment approach, and OTI to NTI conversion. Uniquely, this manuscript reviews all published techniques for converting OTI to NTI and categorizes them into two pathways: direct conversion (with glottic visualization) or indirect conversion (without glottic visualization). Furthermore, original animated videos have been created and attached to help elucidate these conversion techniques visually. Full article

Background/Objectives: Video laryngoscopy is one of the primary methods used by otolaryngologists for detecting and classifying laryngeal lesions. However, the diagnostic process of these images largely relies on clinicians’ visual inspection, which can lead to overlooked small structural changes, delayed diagnosis, and interpretation errors. Methods: AI-based approaches are becoming increasingly critical for accelerating early-stage diagnosis and improving reliability. This study proposes a hybrid Convolutional Neural Network (CNN) architecture that eliminates repetitive and clinically insignificant frames from videos, utilizing only meaningful key frames. Video data from healthy individuals, patients with vocal fold nodules, and those with vocal fold polyps were summarized using three different threshold values with the Structural Similarity Index Measure (SSIM). Results: The resulting key frames were then classified using a hybrid CNN. Experimental findings demonstrate that selecting an appropriate threshold can significantly reduce the model’s memory usage and processing load while maintaining accuracy. In particular, a threshold value of 0.90 provided richer information content thanks to the selection of a wider variety of frames, resulting in the highest success rate. Fine-tuning the last 20 layers of the MobileNetV2 and Xception backbones, combined with the fusion of extracted features, yielded an overall classification accuracy of 98%. Conclusions: The proposed approach provides a mechanism that eliminates unnecessary data and prioritizes only critical information in video-based diagnostic processes, thus helping physicians accelerate diagnostic decisions and reduce memory requirements. Full article

Background: The management of difficult airways is one of the most critical and challenging aspects of emergency and ICU care. Despite technological advances, unanticipated airway difficulty can result in serious complications, including hypoxia, brain injury, and death. This comprehensive narrative review aims to consolidate current algorithms and evidence-based strategies to guide clinicians in the assessment and management of difficult airways. Methods: A comprehensive literature review was conducted using PubMed, Embase, and Google Scholar to identify relevant studies, clinical guidelines, and expert consensus documents related to difficult airway management. The focus was placed on both pre-intubation assessment tools and intervention strategies used in various clinical contexts. Results: Airway difficulty is best anticipated through a combination of history, physical examination, and validated tools such as the Mallampati score. Several algorithms, including those from the American Society of Anesthesiologists (ASA) and the Difficult Airway Society (DAS), provide structured approaches that emphasize preoxygenation, preparedness for failed intubation, and the use of adjuncts such as video laryngoscopy, supraglottic airway devices, and awake intubation techniques. Crisis algorithms such as the Vortex approach help simplify decision-making during emergencies. It is important to have adjuncts available in cases of anticipated difficult airways, such as fiberoptic intubation, while surgical airway access is an important component of a stepwise airway management algorithm when critical scenarios are encountered. Conclusions: Effective difficult airway management requires anticipation, a structured plan, familiarity with advanced airway tools, and adherence to validated algorithms. Training in crisis resource management and multidisciplinary rehearsal of airway scenarios are essential to improving outcomes. Full article

Background: Airway management in otolaryngology presents unique challenges due to shared airway access, altered anatomy, and specific procedural requirements. This article examines current techniques and oxygenation strategies across various ENT procedures to provide a guide for otolaryngologists. Methods: A narrative review was performed of the contemporary literature, focusing on airway techniques in ENT surgery, including laryngeal surgery, pediatric bronchoscopy, transoral surgery, and trauma and emergency scenarios. A systematic search for difficult airway guidelines was performed using the EMBASE, Pubmed, and Cochrane databases to examine where guidelines are published. Results: The key areas for specialist airway management included laryngeal surgery in the tubeless field and adjuncts for emergency situations. High-flow nasal oxygen (HFNO), jet ventilation, video laryngoscopy, and specialized tubes emerged as key technological advances, improving safety and outcomes. A systematic search identified 947 difficult airway articles across 82 publishers. These were predominantly in anesthetic journals (n = 301), with limited representation in the otolaryngology literature (n = 8) and limited guidance concerning awake surgical tracheostomies under local anesthetic. Awake tracheal intubation and emergency front-of-neck access were identified as key techniques across multiple publications. Conclusions: Modern ENT airway management requires multidisciplinary planning, advanced equipment familiarity, and procedure-specific techniques. Despite having the expertise to perform the gold standard, the limited otolaryngology literature on difficult airways suggests that guidelines are primarily developed by the anesthetic community. Full article

Voice disorders occur frequently in schoolteachers. The aim of the present cross-sectional study involving 124 German teachers was to investigate whether singing, voice training, and high self-efficacy are protective factors for vocal health. Furthermore, vocal self-concept was examined as a potential mediator explaining this relationship. Participants were assigned to the cases group if they had a clinically significant finding in voice examinations consisting of video laryngoscopy (VLS), auditory assessment (RBH), and the Voice Handicap Index (VHI) were assigned to the cases group. Psychosocial assessments comprised questions about singing activities and participation in voice training as well as validated questionnaires regarding self-efficacy (LSWS) and vocal self-concept (FESS). Group comparisons and mediation analyses were conducted. Analyses revealed a decreased risk of voice problems for teachers who sing regularly (OR: 0.442, p = 0.038). Furthermore, the absence of voice problems was associated significantly with higher self-efficacy ratings (t(113) = 1.71, p = 0.045). Both associations were mediated by vocal self-concept ratings (singing: ab = −0.422, 95%-CI [−1.102, −0.037]; self-efficacy: ab = −0.075, 95%-CI [−0.155, −0.022]). Participation in voice training in the past did not reduce the risk of voice problems significantly. The presented data suggest that regular singing and self-efficacy should be promoted in health care and prevention programs. Since no impact of sporadic participation in voice training activities on the occurrence of voice problems was found, efforts regarding the transfer of regular vocal exercises into daily life need to be intensified. Full article

This literature review explores factors influencing neonatal ICU intubation success, compares outcomes across settings, and identifies strategies to improve outcomes in this vulnerable population. A PubMed search was conducted using relevant keywords related to neonatal tracheal intubation. Studies published in English from 2000 to 2024 were included, with additional sources identified through manual bibliography reviews. Extracted findings were qualitatively synthesized by themes such as procedural outcomes, intubation setting, and provider training level. Nearly half of all neonatal tracheal intubations (TIs) are unsuccessful, with the rate of tracheal intubation adverse events (TIAEs) increasing with each additional attempt. First-pass success rates (FPSRs) correlate with provider experience, with attending physicians achieving the highest rates across all settings. Video laryngoscopy is associated with improved outcomes, particularly in neonates with difficult airways; however, direct laryngoscopy (DL) remains more commonly used. Premedication has been shown to reduce TIAEs and enhance FPSR, yet it remains underutilized in clinical practice. Standardized protocols, improved simulation-based training, and multidisciplinary strategies are essential to reduce complications. Future research should prioritize optimizing airway management and evaluating the impact of otorhinolaryngologist involvement, especially in difficult airway cases. Full article