Elective tracheal intubation in cervical spine injuries

Patients presenting for surgical stabilisation of an unstable cervical spine are at risk of sustaining a further iatrogenic spinal cord injury during intubation of the trachea. Controversy exists regarding the optimal anaesthetic technique for securing the airway. We reviewed the techniques employed for intubating the trachea in our hospital over a five year period. Tracheal intubation was achieved using two different techniques: awake fibre-optic intubation with local anaesthesia, and general anaesthesia via the intravenous or inhalational route with neuromuscular blockade. Forty five patients were included. 16 patients demonstrated a pre-operative neurological deficit. Awake fibre-optic intubation was used in 27 cases, general anaesthesia was employed via the intravenous route in 17 cases and the inhalational route in 1 case. Weighted traction was employed in all cases to immobilize the cervical spine during intubation. There was no new neurological sequelae with any of these techniques. Our study suggests that there is no optimal anaesthetic technique for intubating the trachea in patients with cervical spine injuries and it is noteworthy that in line traction was used in every case.     

Poxvirus dilemmas--monkeypox, smallpox, and biologic terrorism

Three children with tracheomalacia had tracheal reinforcement with free three-quarter circumference ring grafts of autologous cartilage taken from the costal margin. A low cervical manubrium-splitting approach gave excellent access to the anterior mediastinum and the intrathoracic trachea in two children. The first child, a neonate with oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF), had 11 grafts to support the whole of the trachea from the cricoid to the carina and never required a tracheostomy. For the first 5 years she had frequent pneumonic episodes and on one occasion bilateral pneumothoraces. These episodes and radiographic lung hyperinflation, attributed to distal bronchomalacia, have reduced spontaneously in frequency and severity. At 9 years of age she has a well-supported trachea with palpable cartilage rings in the cervical segment. The trachea has grown to approximately 75% of expected normal size for her age. Another child with tracheomalacia related to innominate-artery compression and who presented with 'dying episodes' was completely relieved and resumed a normal life without a tracheostomy following insertion of four grafts to the intrathoracic trachea. He remains well and symptom-free 8 months postoperatively. A third child had cartilage-graft reinforcement of the lower cervical trachea, including the tracheostomy site, to achieve tracheostomy closure at 16 months of age. Five years later he continues to have a well-supported trachea showing acceptable growth. However, he has ongoing evidence of tracheo-bronchomalacia presenting as expiratory wheezing, lung hyperinflation, and pneumonic episodes that are diminishing spontaneously with growth. Our experience, limited to three children, recommends primary tracheal reinforcement with autologous free costal-cartilage grafts for tracheomalacia in the neonate and young infant. This procedure and the anterior mediastinal approach are well-tolerated, providing instant tracheal support, removing the need for a tracheostomy, and allowing the child's rapid return to the family. Long-term follow-up, presently 9 and 5 years in two children originally presenting with OA and TOF, indicates adequate tracheal growth and an aesthetically acceptable appearance. It is relevant to prognosis that relief of the life-threatening tracheal component exposed the full extent of the bronchial cartilaginous weakness, which has significantly detracted from the quality of life for these two children with OA and TOF-related tracheomalacia.     

Blunt trauma to the trachea

A 5-year-old child sustained blunt trauma to the cervical trachea. Diffuse subcutaneous emphysema of the neck and thorax developed rapidly. Anaesthesia was induced with halothane through a face-piece and the patient breathed spontaneously until the lesion has been evaluated. This course is advocated in the management of such injuries.     

Methodology in puncture tracheostomy. Technique, indications and contraindications

Percutaneous dilatational tracheostomy is a relatively new minimally invasive method for bedside tracheostomy of immobilized adult patients. This procedure is based on the Seldinger technique: after percutaneous puncture of the trachea beneath the cricoid a guidewire is placed into the trachea. Afterwards the wound channel around the wire is dilated until a tracheal cannula can be put in place. The surgeon requires not only precise knowledge of cervical anatomy and manual skills to perform this technique but should also be aware of contraindications and how to proceed if there are technical problems. Based on our personal experience of more than 300 percutaneous dilatational tracheostomies, appropriate recommendations are given.     

Relapsing neoplastic seeding after percutaneous ethanol injection for hepatocellular carcinoma. Clinical and ultrasonographic findings in a cirrhotic patient

The author describes the most useful anastomosis and resection surgical techniques for the treatment of stenosis of cervical trachea. CO2 laser, dilatation, microsurgery, recalibration by external approach and the use of endotracheal tubes are discussed as well.     

The Calvin cycle enzyme sedoheptulose-1,7-bisphosphatase is encoded by a light-regulated gene in Chlamydomonas reinhardtii

OBJECTIVES: Current surgical treatment for a glottic cancer with significant subglottic extension is a total laryngectomy. The objective of this study was to expand laryngeal conservation procedures by using a reconstructive technique that allows for the repair of hemicricolaryngectomy defects. STUDY DESIGN: After resection of the ipsilateral thyroid, cricoid, and arytenoid for advanced T3 glottic cancer, the laryngeal defect was reconstructed by means of an autotransplanted segment of trachea in four patients. The reconstruction consisted of a transferable patch that was constructed from a segment of revascularized cervical trachea. METHODS: During a 14-day period, a 4-cm segment of cervical trachea was wrapped by a free radial forearm fascial flap. In the second stage, the glottic cancer was removed and the cervical trachea was isolated on its fascial blood supply and transformed into a patch that was used to repair the extended hemilaryngectomy defect. Two different patch designs were used. Two patients underwent reconstruction with a patch augmented at the glottic level (group A); two patients underwent reconstruction without glottic augmentation on the patch (group B). Tracheal continuity was restored by an end-to-end reanastomosis. The postreconstruction morphology of the two patch designs was compared with the preoperative laryngeal morphology. RESULTS: The autotransplantation technique led to complete restoration of the subglottic airway lumen in all four patients. Although the anterior-posterior glottic diameter was reduced by 36% in group A patients and by 43.5% in group B patients, a sufficient glottic airway lumen was obtained. The glottic sphincteric function was restored in both groups. CONCLUSIONS: Tracheal autotransplantation may be used reliably to repair hemicricolaryngectomy defects. Augmentation of the patch at the level of the glottis is not essential for successful rehabilitation.     

Beneficial effect of proteases on allograft arteriosclerosis in a rat aortic model

PURPOSE: Our goal was to describe the CT findings in patients with an apparent mass at the thoracic inlet on barium swallow and to further explore its etiology by making appropriate measurements on CT. METHOD: Barium swallows and CT scans of five patients with esophageal pseudomass were reviewed and compared with CT scans of 65 controls. Anteroposterior (AP) diameters of the thoracic inlet were measured, and the relationships of the esophagus to the trachea were determined on CT. RESULTS: Absence of a demonstrable mass on CT in patients with an extrinsic impression on barium swallow was associated with narrowed AP diameter of the thoracic inlet (< 5 cm) and the esophagus to the left of the trachea. A significant correlation was observed between the AP diameter of the inlet and the position of the esophagus in relation to the trachea in control subjects (r = 0.52, p < 0.001); with diminished diameter, the esophagus is more frequently located to the left side of the trachea. CONCLUSION: An apparent mass is simulated by lateral deviation of the lower cervical esophagus, due to diminished available space between the trachea and the esophagus in subjects with a narrow (< 5 cm) AP diameter of the thoracic inlet.     

Traumatic rupture of the cervical trachea. Emergency diagnosis and treatment

The authors report 3 cases of traumatic rupture of the cervical trachea including one associated with total division of the oesophagus. They were impressed by the lack of precision and rapidity of the first surgical measures. They then give an account of the therapeutic gestures which are possible in a non-specialised unit.     

The action of adrenergic substances on the smooth muscle of the rat trachea

Adrenalin and noradrenaline first induced an increase in the trachea smooth muscle response with its subsequent decline in rats. Phentolamine decreases the muscle responses in its thoracic part and practically does not affect it in the cervical segments. The adrenergic neural fibres seem to terminate at the smooth muscle cells and the neurons of intramural ganglia.     

The fiberoptic bronchoscope

The fibertopic bronchoscope was used in 14 cases in the emergency department between September 1974 and September 1976 at Lock Haven Hospital, Lock Haven, Pennsylvania and St. Charles Hospital, Toledo, Ohio. It was used successfully to remove foreign bodies from the trachea and esophagus; in difficult or hazardous endotracheal intubation; intubation in a victim of cardiac arrest with a cervical deformity; evaluation of laryngeal and tracheal injury; localization of bleeding from the posterior nose; evaluation of hemoptysis, and evaluation of thermal injuries from smoke inhalation.     

Rosaceous lymphedema: a rare variant of a common disorder

Surgical reconstruction of the trachea is a relatively complex procedure. We had 20 cases of tracheal stenosis. We have a modest experience of 16 tracheal reconstructions for acquired tracheal stenosis. Two patients underwent laser treatment while another two died before any intervention. The majority of these cases were a result of prolonged ventilation (14 cases), following organophosphorous poisoning (11 cases), Guillain-Barré syndrome, bullet injury, fat embolism and surprisingly only one tumor, a case of mucoepidermoid carcinoma, who had a very unusual presentation. There were 12 males and 4 females in this series, age ranging from 12-35 years. The duration of ventilation ranged from 1-21 days and the interval from decannulation to development of stridor was between 5-34 days. Six of them were approached by the cervical route, 5 by thoracotomy and cervical approach, 2 via median sternotomy and 3 by thoracotomy alone. Five of them required an additional laryngeal drop and 1 required pericardiotomy and release of pulmonary veins to gain additional length. The excised segments of trachea measured 3 to 5 cms in length. All were end to end anastomosis with interrupted Vicryl sutures. We have had no experience with stents or prosthetic tubes. Three patients developed anastomotic leaks which were controlled conservatively. Almost all of them required postoperative tracheo-bronchial suctioning with fibreoptic bronchoscope. We had one death in this series due to sepsis.     

The inferior thyroid veins--the ultimate guardians of the trachea

The inferior thyroid veins and their multiple tributaries are the ultimate guardians of the cervical trachea. Deeply embedded in the pretracheal fat pad, this plexus of veins is consistently encountered during low tracheostomy that accompanies conservation laryngral procedures as well as in tracheal reconstruction. In a high tracheotomy, the handling of the thyroid isthmus is simplified by an appreciation of these veins. Even cricothyrotomy is potentially complicated by hemorrhage sebsequent to a tear in a tributary of the inferior thyroid venous system. A cadaver study, employing 10 embalmed head and neck specimens, was performed to elucidate the tributary patterns of these veins. In every dissection there was at least one and as many as five veins overlying the trachea just below the thyroid isthmus. In 7 of 10 dissections a confluence of right and left inferior thyroid veins formed a large thyroid ima vein draining into the left innominate vein, and in 1 of 10 cases the thyroid ima vein drained into the right innominate. This confluence was present at a level which would be encountered in low tracheostomy or tracheal repair procedures. Six of 10 dissections presented large tributaries of the inferior thyroid veins overlying the cricothyroid membrane. An awareness of such anatomical considerations should result in safer surgical procedure performed in a dry operative field.     

Primary tracheal tumors

A 33-year study (from 1963 through 1995) was conducted on 144 patients who underwent surgery for primary tumors of the trachea: 70 females and 65 males aged between 7 and 69 years. In 77 patients the tumor was in the thoracic trachea, in 26 in the cervical trachea, and in 41 at the tracheal bifurcation. The tumor was benign in 24 and malignant in 120. The most frequent malignant tumors were adenoidcystic carcinoma (more than 50%), squamous cell carcinoma, and carcinoid. The main diagnostic methods used were lateral and oblique roentgenography, tracheobronchoscopy and in the last 10 years, CT scans. One hundred forty-six operations were performed (2 patients underwent surgery twice). In 60, sleeve resection with anastomosis was made; in 37, different kinds of carinal resections were performed. Total hospital mortality was 15%. After resection for malignant tumors, 3-year, 5-year and 10-year survival rates were 47.5%, 35.9%, and 27.1%, respectively.     

Use of ultrasonography in the diagnosis of tracheal collapse

Ultrasonographic imaging of the cervical trachea was performed with the neck in both a neutral and a hyperextended position in 10 dogs with tracheal collapse. Tracheoscopy was used to confirm a diagnosis of tracheal collapse. The ultrasound investigation was repeated in 10 dogs of similar size but without tracheal abnormality. The ultrasonographic findings of the affected dogs were compared with those of the normal group and showed an alteration in the shape of the tracheal lumen in the ventrodorsal projection. This study highlights the possibility of identifying changes in the shape of the tracheal lumen during ultrasound investigations as an aid to the diagnosis of tracheal collapse.     

Porous-type tracheal prosthesis sealed with collagen sponge

BACKGROUND: Reconstruction of a long section of the trachea is clinically problematic. Tracheal reconstructions using prostheses have met with limited success due to local infection, hemorrhage, luminal stenosis and prosthesis dislocation. METHODS: We have designed a porous type of tracheal prosthesis in which the mesh is sealed with collagen sponge. We used this prosthesis (50 mm in length) to reconstruct the cervical trachea in 10 mongrel dogs and evaluated its efficacy. RESULTS: One dog died due to an accident with anesthesia at 6 weeks and 1 of suffocation at 10 weeks. The other 8 dogs had an uneventful postoperative course until they were killed between 6 and 24 months after implantation. At sacrifice, all the prostheses had become completely incorporated into the host. Microscopic examination revealed advanced formation of a new epithelial lining in 1 dog at 6 months, and a confluent epithelial lining was observed in another dog at 12 months. Central stenosis was not significant in any of the animals. CONCLUSIONS: This tracheal prosthesis gives good results in canine tracheal reconstruction, and appears very promising for the clinical repair of tracheal defects.     

A novel procedure for mediastinal vagotomy inhibits neurogenic inflammation in rat bronchial tree

Tachykinin-containing sensory axons originating from the cervical vagal nerves and the first several pairs of thoracic spinal nerves are involved in neurogenic inflammation evoked by capsaicin in the bronchial tree. Unilateral degeneration of the cervical vagal trunk by surgical lesion inhibits neurogenic inflammation in the ipsilateral bronchial airways. The vagal trunk has two main branches, the thoracic vagus nerve and recurrent laryngeal nerve in the thorax. The main purpose of this study was to determine whether the thoracic vagus nerve or recurrent laryngeal nerve was significantly involved in the neural control of bronchial inflammation in the rat. A novel and safe surgical procedure was used for selectively cutting the right thoracic vagal trunk, thoracic vagus nerve, or recurrent laryngeal nerve by introducing the surgical instrument through an aperture between the first and second ribs in the ventral wall of the rostral mediastinum. This surgical operation could be completed without causing a pneumothorax. After 2 postoperative weeks, the effects of denervation on capsaicin-induced plasma extravasation in the respiratory tract were tested. Either right thoracic vagal trunk transection or thoracic vagus section significantly decreased plasma extravasation in the right bronchial tree. Thoracic vagus section was obviously more effective. Evans blue extravasation in the right lobar bronchi was reduced by 44-78% after thoracic vagal trunk transection, while that in the right mainstem and lobar bronchi was reduced by 58-81% after thoracic vagus section. Area densities of India ink-labeled leaky blood vessels in the right lobar bronchi were reduced by 40-65% after thoracic vagal trunk transection, and those in the right mainstem and lobar bronchi were reduced by 83-88% after thoracic vagus neurectomy. Recurrent laryngeal neurectomy did not change the plasma extravasation induced by capsaicin in the trachea and bronchi. These results suggest that capsaicin-sensitive fibers running in the vagal trunk, which largely mediated neurogenic inflammation in the bronchial tree, were projected into the thoracic vagus nerve which, in turn, sent these nerve fibers to the ipsilateral bronchial tree. For the trachea, the remaining sensory fibers surviving denervation might provide sufficient tachykinins to trigger neurogenic inflammation.     

Resection of cancer of lung and carina

In 3-cases in which lung cancer had occurred in the right upper lobe bronchus and had infiltrated the carina, the right upper lobe (including the lower part of the trachea, the carina, and the right main bronchus) was resected, and a new carina was created by anastomosing the trachea with the left main bronchus and the right intermediate trunk. Surgical techniques and the method for anesthesia were described in these 3 cases. To evaluate the function of the reconstructed trachea and bronchus, we made cinebronchograms at the high speed of 100 or 150 frames per second. This bronchographic movie film helped us to determine the state of the reconstructed trachea and bronchus.     

Sustained exposure to a glycine receptor partial agonist differentially alters NMDA receptor agonist and antagonist potencies in cultured spinal cord neurons

The present study examined the effects of K+ channel inhibitors on the basal tone and on KCl- or methacholine-induced contraction of the mouse-isolated trachea. Glibenclamide and iberiotoxin, procaine, quinine and tetraethylammonium did not induce any contraction of the indomethacin-treated mouse trachea. 4-Aminopyridine induced concentration-dependent contraction. This action of 4-aminopyridine was abolished by atropine and reduced by tetrodotoxin and nifedipine. Glibenclamide failed to modify KCl- or methacholine-induced contraction. Iberiotoxin and 4-aminopyridine potentiated KCl- and methacholine-induced contractions. Nifedipine, procaine, quinine and tetraethylammonium inhibited KCl- and methacholine-induced contractions. These data suggest that the closure of large Ca2+-dependent K+ channels can potentiate KCI- and methacholine-induced contraction. The effects of 4-aminopyridine on the mouse trachea reflect chiefly activation of muscarinic receptors. Procaine, quinine and tetraethylammonium inhibit depolarization-induced and receptor-mediated contractions of the mouse-isolated trachea.     

Preoperative neoadjuvant chemotherapy with a combination of 5-fluorouracil, adriamycin and cisplatin (FAP) for advanced esophageal cancer invading trachea or main bronchus

Conventional irradiation and systemic chemotherapy is scarcely effective for advanced esophageal cancer invading trachea or main bronchus. Therefore, to reduce the area of invasion and suppress distant metastasis, we have preoperatively treated 4 patients suffering from advanced esophageal cancer invading the trachea or main bronchus by neoadjuvant chemotherapy (FAP) as follows: 2 times every 4 weeks, CDDP 100 mg and ADR 50 mg on day 1 and continuous infusion of 5-FU 1,000 mg/day for 7 days. The response rate (PR) was 75% (3/4). In 2 of 4 patients (50%), no cancer cells except broad fibrosis were detected histologically in the region of the trachea or main bronchus suspected to be invaded. There was no severe complication. This FAP regimen is suspected to be useful chemotherapy for advanced esophageal cancer.     

Effect of clenbuterol on beta-adrenoceptors and adenylate cyclase activity in smooth muscle and epithelium of the trachea of calves

A potent beta-agonist (clenbuterol) was administered perorally to young calves for 50 days. After this period the animals were slaughtered and beta-adrenoceptor density, ligand affinity, and basal and stimulated adenylate cyclase activities were studied in smooth muscle and epithelium of the trachea. Although the density of lung beta-adrenoceptors was down regulated by clenbuterol, cAMP production remained constant (epithelium) or even increased (smooth muscle). Therefore desensitization of beta-adrenoceptors in the trachea was not observed. This might be a reason for the effectiveness of long-term treatment with beta-agonists.