A 75-year-old woman with mesopharyngeal adenocarcinoma underwent left upper lobectomy for lung adenocarcinoma. Before the operation, computed tomography showed no stricture of the trachea, and laryngoscope showed no abnormality of vocal cord. Spiral tube( 7.5 mm I.D.) was used insted. One lung ventilation was achieved using balloon. It took 4 hours and 3 minutes to finish the surgical procedure. After extubation in the operation room, we did not recognize the breathing abnormality and laryngeal nerve palsy. 4 days after the operation, stridor was noticed, and laryngoscopic examination revealed stenosis of glottis due to bilateral laryngeal nerve paralysis. We performed the emergent tracheotomy. 7 days after the operation, nerve paralysis improved.

OBJECTIVES

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HYPOTHESIS:

To define a new clinical hospitalist practice paradigm originating at the University of California, San Francisco.

DESIGN:

Retrospective administrative database review at a tertiary referral hospital.

MATERIALS AND METHODS:

A consortium model of an otolaryngologist hospitalist practice was developed. Billing records, including Current Procedural Terminology (CPT) and International Classification of Disease-9 (ICD-9) codes, were reviewed to evaluate the number and type of consultations and surgeries generated during a 2-year period.

RESULTS:

A total of 375 new inpatient consultations generated 951 patient encounters. The most common diagnoses were respiratory failure (12%), sinusitis (10.6%), stridor (10.6%), and dysphonia (7.6%). Twenty-six percent of consultations involved a procedure or surgical intervention, the most common of which were endoscopic sinus surgery, laryngoscopy, and tracheotomy.

CONCLUSIONS:

To our knowledge, ours is the first full-time otolaryngology hospitalist model in the United States. The hospitalist practice is a conceptually viable and clinically beneficial paradigm that should be considered at other similar institutions.

LEVEL OF EVIDENCE:

N/A.

Multiple system atrophy (MSA) is associated with respiratory dysfunction, including sleep apnea, respiratory dysrhythmia, and laryngeal stridor. Neurons of the parabrachial nucleus (PBN) control respiratory rhythmogenesis and airway resistance.

Objectives:

The objective of this study is to determine whether there was involvement of putative respiratory regions of the PBN in MSA.

Methods:

We examined the pons at autopsy in 10 cases with neuropathologically confirmed MSA and 8 age-matched controls. Sections obtained throughout the pons were processed for calcitonin-gene related peptide (CGRP) and Nissl staining to identify the lateral crescent of the lateral PBN (LPB) and the Kölliker-Fuse nucleus (K-F), which are involved in respiratory control. Cell counts were performed using stereology.

Results:

There was loss of CGRP neurons in the PBN in MSA (total estimated cell counts for the external LPB cluster was 12,584±1146 in controls and 5917±389 in MSA, p<0.0001); for the external medial PBN (MPB) cluster it was 15,081±1758 in controls and 7842±466 in MSA, p<0.001. There was also neuronal loss in putative respiratory regions of the PBN, including the lateral crescent of the LPB (13,039±1326 in controls and 4164±872 in MSA, p<0.0001); and K-F (5120±495 in controls and 999±308 in MSA, p<0.0001).

Conclusions:

There is involvement of both CGRP and putative respiratory cell groups in the PBN in MSA. Whereas the clinical implications of CGRP cell loss are still undetermined, involvement of the LPB and K-F may contribute to respiratory dysfunction in this disorder.

Disk battery ingestion is common in the pediatric population, with over 50,000 ingestions reported annually. In the upper aerodigestive tract, consequences of such ingestions vary widely from superficial mucosal ulcerations to death from erosion through vital structures. This report describes a battery ingestion complication, vocal cord paralysis, to our knowledge not previously described in the otolaryngology literature.We describe a patient who presented with biphasic stridor and drooling after upper esophageal disk battery ingestion. The battery was removed 5 hours after ingestion, but stridor with respiratory distress persisted. To stabilize the airway, a tracheotomy was performed after a several-week period of inpatient observation. Two years after ingestion, the patient is tracheostomy dependent.Disk battery ingestion has the potential for recurrent laryngeal nerve damage and vocal cord paralysis. Expeditious battery removal and long-term care are crucial for successful ingestion management, as ingestion complications can be significant.

Many species respond to increases in environmental noise by increasing the amplitude, duration, and/or repetition rate of their vocalizations. Potential costs of noise-induced vocal modifications include increased energetic costs but no empirical data in marine mammals exist. This study's objective was to compare the metabolic costs of communicative sounds produced by captive bottlenose dolphins (N = 2) under two conditions (low- and high-amplitude vocalization trials) to assess energetic costs of vocal responses to noise. An experimental trial consisted of a 10-min rest period to determine resting metabolic rate, followed by a two-minute vocalization period, and concluded with another 10-min rest period to measure recovery. Open-flow respiratory was used to measure oxygen consumption during each trial component. Vocalizations were recorded using a calibrated hydrophone for analysis. Both dolphins tended to produce longer vocalizations during high-amplitude trials. Thus, metabolic rates were related to total sound energy of all vocalizations produced during the vocal period for each trial. Metabolic costs tended to be higher during high sound energy trials, but only verged on statistical significance when vocal-performance differences were at least 10 dB (in cumulative sound exposure level). This study provides key data to assess biological consequences of anthropogenic noise exposure in marine mammals.

Obstructive sleep apnea (OSA) refers to the condition in which a person's breathing is paused while asleep, or the airflow is decreased, due to obstruction in the upper respiratory airway. In severe cases, OSA can cause complete arousals and deprive the patient from normal sleep. Surgical intervention is sometimes recommended, but accurate identification of the site of obstruction can be difficult. In the present study, we devised signal processing methods to estimate the site and the severity of airflow obstruction from recordings of sounds of snore. The vocal tract, the oral and the nasal cavity are modeled as three branches joining at the pharynx. Each branch consists of cylindrical segments whose cross-section areas can vary during snoring. Estimation of these cross-section areas consists of two steps: First, an auto-regressive moving-average method is applied to find the linear coefficients of a pole-zero model that optimally accounts for the recorded sound. Then, the Levinson-Durbin algorithm is applied to convert the coefficients to ratios of cross-section areas between adjacent segments. The present method is applied to a set of recorded snore samples during clinically confirmed apnea episodes, and results are compared with those of simple snore. Effectiveness of the method is analyzed statistically.

Many animal species, including elephants and okapi, use sounds above and below the range of human hearing to communicate. A longitudinal study presented here suggests giraffe produce infrasonic vocalizations using Helmholtz resonance. Recordings were made of giraffe (Giraffe camelopardalis) in controlled indoor conditions and naturalistic outdoor conditions. The portable recording and analysis system consisted of a trigger oscilloscope; DAT recorders; Nagra IV-SJ; and computers. Each signal was low-pass/high-pass filtered, and FFT and STFT were performed using PolynesiaTM real-time scrolling analysis. In controlled recordings and in naturalistic situations, two types of signals were identified: audible bursts [(11 Hz (75 dB +/- 3) to 10,500 Hz (80 dB +/- 3)] dominant frequencies between 150 and 200 Hz and covert vocalizations [(14 Hz (60 dB +/- 3) to 250-275 Hz (30 dB +/- 3)] dominant frequencies between 20 and 40 Hz. Both audible and covert signals coincided with neck throw or head toss behaviors. The shape of the giraffe's respiratory apparatus during this behavior and the frequencies produced implicate Helmholtz resonance as a production mechanism. In naturalistic recordings, two of the five infrasonic vocalizations identified were produced during close range social interactions, suggesting that giraffe use these vocalizations to communicate with con-specifics. The social functions, air and seismic transmission mechanisms of these vocalizations should be further assessed.

Diagnosis of pulmonary emphysema by using a stethoscope is based on the common knowledge that abnormal respiratory (adventitious) sounds usually appear in patients with pulmonary emphysema. However, the spectral similarity between adventitious sounds and noises at auscultation makes highly accurate automatic detection of adventitious sounds difficult. In this paper, we have proposed a novel method for distinguishing between normal lung sounds in healthy subjects and abnormal sounds, including adventitious sounds in patients, taking into account the occurrence tendency of adventitious sounds and noises. According to our investigation results, adventitious sounds occur repeatedly in successive inspiratory/expiratory phases of patients. On the other hand, noise sounds mix at random in lung sounds of both patients and healthy subjects. In our method, the occurrence tendency of these sounds is described using Gaussian distribution of a random variable obtained by subtracting the acoustic likelihood for abnormal respiration from the likelihood for normal respiration. The spectral likelihood calculated using hidden Markov models and the validity score of the occurrence tendency of the adventitious/noise sounds are combined to derive the classification result. Our method achieved a higher classification rate of 94.1% between normal and abnormal lung sounds than that achieved using the conventional method (87.4%).

Gastro-esophageal reflux (GERD) is highly prevalent in children and there is a tendency to disappear or decrease its frequency in the first year. However, in certain circumstances this reflux can have adverse consequences and these cases are known as gastro-esophageal reflux disease (GERD). The clinical manifestations of GERD include typical and atypical or extra digestive symptoms. The association between GERD and chronic laryngeal symptoms may present clinically as recurrent croup, stridor, chronic or intermittent hoarseness, globus sensation, excessive chronic cough and posterior rhinorrhea. Multi-channel intraluminal impedance-pH 24 hours (IIM-pH 24h) is the diagnostic method of choice for the study of this association.To describe the behavior and characteristics of GERD in patients with recurrent laryngitis.This is a retrospective study involving pediatric patients with recurrent laryngitis (2 or more episodes in 6 months) referred for study of possible GERD.We evaluated 28 children. Only 7 of them had normal studies.There is a significant percentage of patients with normal 24 hour Ph monitoring that had not been diagnosed with GERD without IIM. There was not a characteristic pattern.

Clinical trials exploring optimal sedation management in critically ill pediatric patients are urgently needed to improve both short- and long-term outcomes. Concise operational definitions that define and provide best-available estimates of sedation-related adverse events (AE) in the pediatric population are fundamental to this line of inquiry.To perform a multiphase systematic review of the literature to identify, define, and provide estimates of sedation-related AEs in the pediatric ICU setting for use in a multicenter clinical trial.In Phase One, we identified and operationally defined the AE. OVID-MEDLINE and CINAHL databases were searched from January 1998 to January 2012. Key terms included sedation, intensive and critical care. We limited our search to data-based clinical trials from neonatal to adult age. In Phase Two, we replicated the search strategy for all AEs and identified pediatric-specific AE rates.We reviewed 20 articles identifying sedation-related adverse events and 64 articles on the pediatric-specific sedation-related AE. A total of eleven sedation-related AEs were identified, operationally defined and estimated pediatric event rates were derived. AEs included: inadequate sedation management, inadequate pain management, clinically significant iatrogenic withdrawal, unplanned endotracheal tube extubation, post-extubation stridor with chest-wall retractions at rest, extubation failure, unplanned removal of invasive tubes, ventilator-associated pneumonia, catheter-associated bloodstream infection, Stage II+ pressure ulcers and new tracheostomy.Concise operational definitions that defined and provided best-available event rates of sedation-related AEs in the pediatric population are presented. Uniform reporting of adverse events will improve subject and patient safety.