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Anaesthesiology Intensive Therapy 2019To the Editor, Nasotracheal intubation is a widely used technique in anaesthesia management for procedures including oropharyngeal, dental, and maxillofacial...
To the Editor, Nasotracheal intubation is a widely used technique in anaesthesia management for procedures including oropharyngeal, dental, and maxillofacial surgeries[1-3]. It provides an uninhibited access to the mouth and plays an important role when dealing with difficult airways[4-6]. It is also used in patients with cervical spine instability owing to injury[7] or in patients with a cervical spine fixation owing to a disease or previous operation[8]. Moreover, it is selected for patients who require prolonged intubation for intensive care[9]. However, nasotracheal intubation may lead to certain complications, with epistaxis being the most common. Epistaxis generally occurs due to damage of the Kiesselbach's plexus in the anterior part of the nasal septum[10-12] where branches from several arteries, including branches of the ophthalmic, maxillary, and facial arteries, anastomose to form a vascular plexus. To avoid this complication, the tracheal tube should be inserted into the nasal cavity such that its bevel tip comes to the lateral side of naris. However, if the bleeding occurs on insertion of the tube, the nasotracheal intubation should be completed to chiefly protect the airway and also to tamponade the bleeding point. Risk of sinusitis is another disadvantage associated with nasotracheal intubation[13]. Sinusitis can induce oedema around the opening of the maxillary sinus. Mucosal oedema in the nasopharynx can also result in the middle-ear problem. Superficial necrosis of the nasal ala is another common complication associated with the nasotracheal intubation[3,9,14,15]. Several measures have been suggested to avoid this necrosis problem [15-18]; however, these measures cannot always be applied in paediatric patients as their naris do not provide enough space for them. Nasotracheal intubation has also been reported to cause bacteraemia owing to abrasion of the nasal mucosa [19,20]. The nasotracheal intubation-related carriage of bacteria into the trachea should be also avoided. It is reported that prior treatment of nostrils and anterior nasal septum with mupirocin is effective to avoid this complication[21,22]. However, the cheapest and easiest countermeasure to avoid such a complication during the nasotracheal intubation for inducing anaesthesia involves removal of the nasal dirt from the tip of the tracheal tube; in short, the tracheal tube should be pulled out with the aid of Magill forceps through the patient's mouth and the dirt should be wiped with a clean cotton (Figure 1). Additionally, dirt from the pharynx should be completely sucked under direct vision laryngoscope if required, before advancing the tracheal tube into the larynx. Once the tube tip and the pharynx are cleaned, the tube should be pulled again into the oral cavity by pulling the proximal side of the tube near the patient's nostril. Subsequently, the tube tip can be advanced into the larynx with the aid of Magill forceps. This series of treatment does not take longer than 10 seconds to perform once the anaesthesiologist and nurse anaesthetist get accustomed to it, thereby preventing an extreme fall in the peripheral capillary oxygen saturation (SpO2), even in paediatric patients. If the SpO2 value goes below the permissible range during the procedure, the patient can be easily ventilated by connecting the ventilation hose from the anaesthesia machine to the tracheal tube thereby completely closing the nose and mouth of patient (Figure 2), whereas some anaesthesiologists believe that the tracheal tube should be completely drawn from the patient's nose again to ventilate the patient with a mask On the other hand, some anaesthesiologists advance the tracheal tube further into the trachea in almost a panic condition, even when they have recognised the nose dirt on its tip (Figure 3), to prevent SpO2 fall, especially in paediatric patients. Therefore, knowledge of the ventilation technique via the tracheal tube inserted in the patient's nostril can be of great advantage while performing nasotracheal intubation. It can allow anaesthesiologists to calmly pull out the tip of tracheal tube using Magill forceps through the patient's mouth, when they recognise the nose dirt on it, to advance a cleaned tracheal tube into the trachea, even in paediatric patients. In conclusion, we suggest a simple countermeasure to avoid possible complications of nasotracheal intubation. It involves movement of a cleaned tracheal tube into the trachea of patient. Moreover, we suggest a possible ventilation technique in case the SpO2 falls beyond the permissible range during the nasotracheal intubation.
Topics: Bacteremia; Epistaxis; Humans; Intubation, Intratracheal; Nasal Mucosa; Necrosis; Sinusitis
PubMed: 30723887
DOI: 10.5603/AIT.a2019.0002 -
PloS One 2020Memory B cell (mBC) induction and maintenance is one of the keys to long-term protective humoral immunity. MBCs are fundamental to successful medical interventions such...
Human CD27+ memory B cells colonize a superficial follicular zone in the palatine tonsils with similarities to the spleen. A multicolor immunofluorescence study of lymphoid tissue.
BACKGROUND
Memory B cell (mBC) induction and maintenance is one of the keys to long-term protective humoral immunity. MBCs are fundamental to successful medical interventions such as vaccinations and therapy in autoimmunity. However, their lifestyle and anatomic residence remain enigmatic in humans. Extrapolation from animal studies serves as a conceptual basis but might be misleading due to major anatomical distinctions between species.
METHODS AND FINDINGS
Multicolor immunofluorescence stainings on fixed and unfixed frozen tissue sections were established using primary antibodies coupled to haptens and secondary signal amplification. The simultaneous detection of five different fluorescence signals enabled the localization and characterization of human CD27+CD20+Ki67- mBCs for the first time within one section using laser scanning microscopy. As a result, human tonsillar mBCs were initially identified within their complex microenvironment and their relative location to naïve B cells, plasma cells and T cells could be directly studied and compared to the human splenic mBC niche. In all investigated tonsils (n = 15), mBCs appeared to be not only located in a so far subepithelial defined area but were also follicle associated with a previous undescribed gradual decline towards the follicular mantle comparable to human spleen. However, mBC areas around secondary follicles with large germinal centers (GCs) in tonsils showed interruptions and a general widening towards the epithelium while in spleen the mBC-containing marginal zones (MZ) around smaller GCs were relatively broad and symmetrical. Considerably fewer IgM+IgD+/- pre-switch compared to IgA+ or IgG+ post-switch mBCs were detected in tonsils in contrast to spleen.
CONCLUSIONS
This study extends existing insights into the anatomic residence of human mBCs showing structural similarities of the superficial follicular area in human spleen and tonsil. Our data support the debate of renaming the human splenic MZ to 'superficial zone' in order to be aware of the differences in rodents and, moreover, to consider this term equally for the human palatine tonsil.
Topics: Adolescent; Adult; Aged; B-Lymphocytes; Cellular Microenvironment; Child; Germinal Center; Humans; Middle Aged; Palatine Tonsil; Spleen; Tumor Necrosis Factor Receptor Superfamily, Member 7
PubMed: 32187186
DOI: 10.1371/journal.pone.0229778 -
European Journal of Immunology May 2013Plasmacytoid pre-dendritic cells (pDCs) are specialized in responding to nucleic acids, and link innate with adaptive immunity. Although the response of pDCs to viruses...
Plasmacytoid pre-dendritic cells (pDCs) are specialized in responding to nucleic acids, and link innate with adaptive immunity. Although the response of pDCs to viruses is well established, whether pDCs can respond to extracellular bacteria remains controversial. Here, we demonstrate that extracellular bacteria such as Neisseria meningitidis, Haemophilus influenzae, and Staphylococcus aureus activate pDCs to produce IFN-α, TNF-α, IL-6, and to upregulate CD86 expression. We observed that pDCs were present within tonsillar crypts and oro-nasopharyngeal epithelium, where they may contact extracellular bacteria, in situ. Tonsil epithelium-conditioned supernatants inhibited IFN-α, TNF-α, and IL-6 triggered by the direct contact of N. meningitidis or S. aureus with pDCs. However, pDC priming of naive T cells was not affected, suggesting that tonsil epithelium micro-environment limits local inflammation while preserving adaptive immunity in response to extracellular bacteria. Our results reveal an important and novel function of pDCs in the initiation of the mucosal innate and adaptive immunity to extracellular bacteria.
Topics: Adaptive Immunity; Adenoids; B7-2 Antigen; Cell Communication; Coculture Techniques; Culture Media, Conditioned; Dendritic Cells; Epithelial Cells; Haemophilus influenzae; Humans; Immunity, Innate; Immunity, Mucosal; Interferon-alpha; Interleukin-6; Lymphocyte Activation; Neisseria meningitidis; Respiratory Mucosa; Staphylococcus aureus; T-Lymphocytes; Tumor Necrosis Factor-alpha; Up-Regulation
PubMed: 23436642
DOI: 10.1002/eji.201242990 -
Brazilian Journal of Otorhinolaryngology 2019The pectoralis major flap is a reconstructive option to consider in the treatment of pharyngocutaneous fistula after a total laryngectomy. There are not large studies...
INTRODUCTION
The pectoralis major flap is a reconstructive option to consider in the treatment of pharyngocutaneous fistula after a total laryngectomy. There are not large studies assessing variables related to pharyngocutaneous fistula recurrence after removal of the larynx. Our objectives were to review the results obtained with this type of treatment when pharyngocutaneous fistula appears in laryngectomized patients, and to evaluate variables related to the results.
METHODS
We retrospectively reviewed our results using either a myocutaneous or fasciomuscular pectoralis major flap to repair pharyngocutaneous fistula in 50 patients.
RESULTS
There were no cases of flap necrosis. Oral intake after fistula repair with a pectoralis major flap was restored in 94% of cases. Fistula recurrence occurred in 22 cases (44%), and it was associated with a lengthening of the hospital stay. Performing the flap as an emergency procedure was associated with a significantly higher risk of fistula recurrence. Hospital stay was significantly shorter when a salivary tube was placed.
CONCLUSIONS
The pectoralis major flap is a useful approach to repair pharyngocutaneous fistula. Placing salivary tubes during fistula repair significantly reduces hospital stay and complication severity in case of pharyngocutaneous fistula recurrence.
Topics: Aged; Cutaneous Fistula; Female; Humans; Laryngectomy; Male; Middle Aged; Pectoralis Muscles; Pharyngeal Diseases; Postoperative Complications; Retrospective Studies; Surgical Flaps; Treatment Outcome
PubMed: 29650373
DOI: 10.1016/j.bjorl.2018.03.002 -
European Annals of Otorhinolaryngology,... Apr 2015Reconstruction of the pharynx and upper esophagus uses various procedures, including pedicled or free flap. Pharyngoplasty with free forearm flap provides excellent...
Reconstruction of the pharynx and upper esophagus uses various procedures, including pedicled or free flap. Pharyngoplasty with free forearm flap provides excellent functional results. In radiation-related pharyngeal stenosis, recipient vascularization is often poor, especially in the venous system. The authors describe pharyngeal reconstruction with semi-free forearm flap, pedicled on the cephalic vein, to minimize the risk of venous thrombosis, which is the main factor of free forearm flap necrosis. Taking the case of a laryngectomy with complete pharyngeal stenosis after radiation therapy and iterative neck surgery, the technique of pharyngeal-esophageal reconstruction by semi-free forearm flap is described in a context of impaired vascularization.
Topics: Carcinoma, Squamous Cell; Esophagoplasty; Forearm; Free Tissue Flaps; Humans; Laryngeal Neoplasms; Laryngoplasty; Male; Middle Aged; Pharyngectomy; Plastic Surgery Procedures; Treatment Outcome
PubMed: 25482241
DOI: 10.1016/j.anorl.2014.09.002 -
Chinese Journal of Cancer May 2010The tonsils are the most commonly involved primary part of non Hodgkin's lymphoma (NHL) of the head and neck, which usually happens in the Waldeyer's ring. Our study...
BACKGROUND AND OBJECTIVE
The tonsils are the most commonly involved primary part of non Hodgkin's lymphoma (NHL) of the head and neck, which usually happens in the Waldeyer's ring. Our study describes the features of computed tomography on enlarged tonsils as a first symptom of NHL and the characteristics of the involved cervical lymph nodes.
METHODS
A retrospective review was performed on 130 patients with primary extranodal lymphomas of the head and neck over 16 years. Of them 22 untreated patients showed tonsil lesions as a first symptom.
RESULTS
Bilateral enlarged tonsils were involved in 13 patients, and unilateral lesions were in 9 patients. The lesions in 20 patients appeared mass like, while 2 patients had diffuse thickening. There were 8 patients with simultaneous invasion of the nasopharynx, soft palate, and epiglottis. Of the 19 patients that underwent enhanced CT scans, 15 patients demonstrated slight homogeneous enhancement, 4 with crannied or a patch of low density, and 1 with ring like enhancement. All 22 patients appeared to have cervical lymph nodes involvement. The upper groups of cervical lymph nodes were involved bilaterally in 13 patients, unilaterally in 9 patients. The middle groups were involved bilaterally in 7 patients, unilaterally in 10 patients. The lower groups were involved bilaterally in 2 patients, and unilaterally in 5 patients. After contrast administration, lymph nodes showed homogeneous density and slight enhancement in 11 patients, heterogeneous enhancement with necrosis and cystic changes in 6 patients, and ring like enhancement in 2 patients.
CONCLUSIONS
Bilateral involvement, homogeneous density, and slight enhancement are characteristics of tonsil involvement of non Hodgkin's lymphoma. Bilateral upper groups of cervical lymph nodes are the most frequently involved lymph nodes, which are often shown with homogeneous density and slight enhancement.
Topics: Adolescent; Adult; Aged; Female; Head and Neck Neoplasms; Humans; Lymph Nodes; Lymphatic Metastasis; Lymphoma, Large B-Cell, Diffuse; Lymphoma, Non-Hodgkin; Male; Middle Aged; Neck; Neoplasm Invasiveness; Palatine Tonsil; Retrospective Studies; Tomography, X-Ray Computed; Young Adult
PubMed: 20426908
DOI: 10.5732/cjc.009.10524 -
Acta Otorhinolaryngologica Italica :... Jun 2020
Topics: Adult; Aged; Aged, 80 and over; Female; Free Tissue Flaps; Humans; Male; Middle Aged; Mouth; Myocutaneous Flap; Neck; Oropharynx; Plastic Surgery Procedures; Retrospective Studies; Superficial Musculoaponeurotic System
PubMed: 32773778
DOI: 10.14639/0392-100X-N0538 -
Lancet (London, England) Jul 2003The worldwide outbreak of severe acute respiratory syndrome (SARS) is associated with a newly discovered coronavirus, SARS-associated coronavirus (SARS-CoV). We did...
BACKGROUND
The worldwide outbreak of severe acute respiratory syndrome (SARS) is associated with a newly discovered coronavirus, SARS-associated coronavirus (SARS-CoV). We did clinical and experimental studies to assess the role of this virus in the cause of SARS.
METHODS
We tested clinical and postmortem samples from 436 SARS patients in six countries for infection with SARS-CoV, human metapneumovirus, and other respiratory pathogens. We infected four cynomolgus macaques (Macaca fascicularis) with SARS-CoV in an attempt to replicate SARS and did necropsies on day 6 after infection.
FINDINGS
SARS-CoV infection was diagnosed in 329 (75%) of 436 patients fitting the case definition of SARS; human metapneumovirus was diagnosed in 41 (12%) of 335, and other respiratory pathogens were diagnosed only sporadically. SARS-CoV was, therefore, the most likely causal agent of SARS. The four SARS-CoV-infected macaques excreted SARS-CoV from nose, mouth, and pharynx from 2 days after infection. Three of four macaques developed diffuse alveolar damage, similar to that in SARS patients, and characterised by epithelial necrosis, serosanguineous exudate, formation of hyaline membranes, type 2 pneumocyte hyperplasia, and the presence of syncytia. SARS-CoV was detected in pneumonic areas by virus isolation and RT-PCR, and was localised to alveolar epithelial cells and syncytia by immunohistochemistry and transmission electron microscopy.
INTERPRETATION
Replication in SARS-CoV-infected macaques of pneumonia similar to that in human beings with SARS, combined with the high prevalence of SARS-CoV infection in SARS patients, fulfill the criteria required to prove that SARS-CoV is the primary cause of SARS.
Topics: Animals; China; Communicable Diseases, Emerging; Disease Models, Animal; Disease Outbreaks; Global Health; Humans; Macaca fascicularis; Pulmonary Alveoli; Severe acute respiratory syndrome-related coronavirus; Severe Acute Respiratory Syndrome
PubMed: 12892955
DOI: 10.1016/S0140-6736(03)13967-0 -
Cellular Immunology Jul 2019IgA nephropathy (IgAN) is a tonsil-related disease. We previously showed that oligodeoxynucleotides with CpG (CpG-ODN) and B-cell activation factor (BAFF) are involved...
IgA nephropathy (IgAN) is a tonsil-related disease. We previously showed that oligodeoxynucleotides with CpG (CpG-ODN) and B-cell activation factor (BAFF) are involved in hyperproduction of IgA from tonsillar mononuclear cells of patients with IgAN (IgAN-TMCs). In this study, we focused on a proliferation-inducing ligand (APRIL), homologous to BAFF. IgAN-TMCs produced more APRIL than non IgAN-TMCs in the presence of both CpG-ODN and control-ODN. TLR9 expression was higher in B-cells of IgAN-TMCs, and treatment with CpG-ODN enhanced transmembrane activator and CAML interactor (TACI) expression. IgA production from IgAN-TMCs was inhibited by APRIL neutralization antibody or TACI blocking antibody, and enhanced by co-treatment of APRIL and CpG-ODN. Serum APRIL levels were higher in patients with IgAN, and decreased after tonsillectomy. These findings suggest that APRIL is involved in the hyperproduction of IgA from IgAN-TMCs, and that CpG-ODN enhanced APRIL-induced IgA production by increasing TACI expression on B-cells of IgAN-TMCs.
Topics: Adolescent; Adult; Aged; Antibodies, Neutralizing; B-Cell Activating Factor; B-Lymphocytes; Gene Expression Regulation; Glomerulonephritis, IGA; Humans; Leukocytes, Mononuclear; Male; Middle Aged; Oligodeoxyribonucleotides; Palatine Tonsil; Signal Transduction; Toll-Like Receptor 9; Tonsillectomy; Transmembrane Activator and CAML Interactor Protein; Tumor Necrosis Factor Ligand Superfamily Member 13
PubMed: 31088610
DOI: 10.1016/j.cellimm.2019.103925 -
Head and Neck Pathology Jun 2012Abnormalities in cell cycle regulation, tumor suppressor gene functions and apoptosis are frequent events in tumorigenesis. Their role in the pathogenesis and prognosis...
Abnormalities in cell cycle regulation, tumor suppressor gene functions and apoptosis are frequent events in tumorigenesis. Their role in the pathogenesis and prognosis of primary mucosal melanomas (MM) of the upper aerodigestive tract remains unknown. Sixty-four patients (40 men, 24 women, median age 64 years) with MM were included in this study; 32 had tumors in the nasal/paranasal cavities, 28 in the oral cavity and 4 in the pharynx. Archival tissues from 47 initial mucosal tumors, 17 mucosal recurrences, and 13 nodal/distant metastases were subjected to immunohistochemistry using antibodies against p16, p53, and bcl-2. The results were correlated with histological features and survival data. Expressions of p16, p53, and bcl-2 proteins were seen in 25% (N=19/76), 21% (N=16/76), and 74% (N=56/76) of all tumors, respectively. bcl-2 expression in the initial tumors was associated with significantly longer overall and disease specific survival (3.3 vs. 1.5 years, P ≤ 0.05). Expression of p16 was increasingly lost, from 32% in initial tumors to 12% in recurrent and 15% in metastatic tumors (P=0.06). Tumors comprised of undifferentiated cells were significantly more p53 positive than epithelioid or spindle cells (80% vs. 33%, P=0.02). Expression of these markers did not correlate with necrosis, or vascular and/or deep tissue invasion. Expression of bcl-2 is associated with better survival in MM. Loss of p16 was seen with tumor progression whereas aberrant p53 expression was frequent in undifferentiated tumor cells.
Topics: Adult; Aged; Aged, 80 and over; Apoptosis; Biomarkers, Tumor; Cell Cycle; Cyclin-Dependent Kinase Inhibitor p16; Female; Head and Neck Neoplasms; Humans; Kaplan-Meier Estimate; Male; Melanoma; Middle Aged; Mucous Membrane; Neoplasm Staging; Prognosis; Proto-Oncogene Proteins c-bcl-2; Tumor Suppressor Protein p53; Young Adult
PubMed: 22160615
DOI: 10.1007/s12105-011-0319-2