Introduction Polysomnography (PSG) is considered the gold standard diagnostic test for obstructive sleep apnea (OSA) in children. However, the anatomic location of upper airway obstruction in these patients cannot be determined by PSG, especially in children with complex upper airway obstruction. CT imaging and endoscopic evaluation have been proposed for the evaluation of upper airways in these children. However, cinematic magnetic resonance imaging (Cine-MRI) is a safer, less invasive, and potentially more useful tool for dynamic and anatomical evaluation of upper airways. We here describe the diagnostic outcomes of Cine-MRI in our cohort of children with OSA and suspected complex upper airway obstruction. Methods A retrospective chart review of clinical and radiological data of all children with PSG confirmed diagnosis of OSA and who underwent upper airway evaluation using Cine-MRI. Upper airways were evaluated at three different levels: nasopharynx, oropharynx, and supraglottic, during both inspiration and expiration. Fractional collapse (FC) at different levels was used to evaluate dynamic airway collapse and was defined as the difference between maximum and minimum airway dimensions divided by the maximum dimensions. Results Eight children (five females and three males) were included. Median age was 8.5 months (range: one month to 16 years). Cine-MRIs identified upper airway obstruction in all patients. Additionally, 50% of the patients had more than one level of obstruction, mainly the nasopharynx and oropharynx. There was a positive correlation between the apnea-hypopnea index (AHI) and FC in the anteroposterior dimension at the nasopharyngeal and the oropharyngeal levels, but it did not reach statistical significance. However, there was a statistically significant negative correlation between AHI and FC in the transverse dimension at the oropharyngeal level. Cine-MRI was helpful in continuous positive airway pressure (CPAP) titration in two patients and was helpful in planning surgical intervention in two patients. Conclusion Cine-MRI is a helpful diagnostic tool in evaluating patients with complex upper airway obstruction and can direct potential surgical and non-surgical intervention in pediatric patients with complex upper airway obstruction.

The Tübingen Palatal Plate (TPP) is a minimally invasive yet highly effective functional orthodontic treatment for upper airway obstruction in infants with Robin Sequence (RS). It consists of a palatal plate to cover the cleft and a velar extension that shifts the root of the tongue forward. We review our practical experience with this approach. First, upon admission, our local orthodontists perform an (3-D) intraoral scan of the maxilla. Based on the scan data, the TPP is manufactured in a semi-digital workflow. The length and angulation of its extension is checked via awake laryngoscopy and the effectiveness confirmed by a sleep study. Plates are kept in place by adhesive cream. When inserting the TPP, the tip of the tongue must be visible. Next, metal fixation bows should be secured to the forehead using tape and elastic bands. Plates are removed daily for cleaning, and the oral mucosa is then checked for pressure marks. Feeding training (initially only via finger feeding) may even start before plate insertion. Breathing often normalizes immediately once the plate is inserted. For isolated RS, we have never had to perform a tracheostomy. This has largely been possible through our highly dedicated and competent team, particularly the nursing staff, and the early involvement of parents.

BACKGROUND: Negative pressure pulmonary edema (NPPE) is a potentially life-threatening complication that develops rapidly following acute upper airway obstruction. The condition is rare, dramatic but resolves quickly. Prompt recognition and appropriate supportive treatment may prevent unnecessary investigations and iatrogenic complications.
METHODS: We describe a spectrum of etiologies and clinical manifestation of pediatric NPPE in our center and review of previous publications.
CONCLUSIONS: The etiology for the development of NPPE in children has shifted over the years. Although dramatic in presentation, this type of pulmonary edema often resolves quickly with minimal support.

Negative-pressure pulmonary edema (NPPE) is an uncommon diagnosis that requires a high clinical suspicion to recognize and manage and has high morbidity and mortality. It usually results secondary to markedly negative intrapleural pressure due to the forceful inspiration against the obstructed airway from upper airway infection, tumor, or laryngospasm. We present a case of a 27-year-old female with morbid obesity who underwent sleeve gastrectomy and developed NPPE upon emergence from anesthesia. The focus of supportive care should be on addressing the obstruction in the upper airway through either endotracheal intubation or cricothyroidotomy. Additionally, it is important to initiate lung-protective positive-pressure ventilation and promote diuresis, unless the patient is in a state of shock. The resolution of pulmonary edema is typically swift, partially due to the preservation of alveolar fluid clearance mechanisms. In the literature review, we delve into the clinical presentation, pathophysiology, and management of NPPE or post-obstructive pulmonary edema.

This study\'s objective is to systematically review the literature on natural sleep endoscopy (NSE), including the set-up, different scoring systems, visualized collapse patterns during natural sleep, additional measurements, and comparison of upper airway collapse between NSE and drug-induced sleep endoscopy (DISE). A computerized search on Medline, Web of Science and the Cochrane library was conducted, obtaining 39 hits. Ten prospective studies were included in which NSE was performed in adults with obstructive sleep apnea (OSA). This study\'s findings suggest the soft palate to be the most frequent site of obstruction (58.8 %), followed by the tongue base (43.2 %), lateral walls (29.9 %), and epiglottis (22.4 %), which is in line with previous findings during DISE. Based on this literature review, the authors conclude that at this stage high quality, comparative research between DISE and NSE is missing. To adequately compare findings between OSA patients, endoscopic classification of upper airway collapse should be standardized. Non-invasive predictive tools to determine pharyngeal collapse are currently under investigation and may obviate the need for invasive endoscopy. This review highlights the contribution of NSE in validating such novel diagnostic methods and in studying upper airway mechanics in a research setting, yet larger and adequately powered studies are needed.

OBJECTIVE: Pediatric tracheostomy is performed in a variety of complex, comorbid patients. Tracheostomy involves a significant burden of care for families and a risk of life-threatening complications. There is little research regarding the ideal location and protocol for safe tracheostomy decannulation. This study aims to determine patient factors that may be predictive of trial of tracheostomy decannulation being able to take place safely outside of the intensive care setting.
METHODS: A 10-year retrospective review of all decannulation trials at our institution is used to assess for patient factors associated with a higher risk of decannulation failure. The timing of failure and the interventions required to secure the patient\'s airway are reviewed. This data is used to inform recommendations regarding location of tracheostomy decannulation trial and length of inpatient stay, aiming to rationalize the use of resources while maintaining safe tracheostomy decannulation practices.
RESULTS: One hundred and fifty-eight decannulation events occurred in 131 children over the study period, resulting in 132 successful decannulations (83.5%). Twenty-six failed episodes (16.5%) occurred in 16 patients (12.2%). Ten of these patients were successful on a second decannulation attempt and six had two or more failed decannulation attempts (4.6%). Failed decannulation was higher in patients with upper airway obstruction as the indication for tracheostomy (20.3% failure rate versus 0%). History of prematurity was significantly associated with failure of decannulation. Nine decannulation failures occurred immediately, with a further 9 failures occurring within the first 24 hours. A further 3 failures occurred in hospital and 5 following discharge. No mortality or significant morbidity occurred during any decannulation trial.
CONCLUSIONS: Our study identified a higher rate of decannulation failure in patients with upper airway obstruction, suggesting that decannulation trials for this subgroup should occur in the intensive care unit. Patients with tracheostomy for other indications may be safe to decannulate in a ward setting. Early failures demonstrated more rapid deterioration. Further research is recommended on the utilization of capping trials or polysomnography prior to decannulation to help guide the ideal location and timing for trial decannulation.

Background: Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by the ossification of entheses. When localized in the cervical paravertebral region, typical signs and symptoms include stiffness, pain, loss of range of motion, and difficulty swallowing. Clinical Presentation: The authors present two less typical respiratory manifestations of DISH due to cervical osteophytes protrusion and obstruction of the upper airway. The first patient was treated conservatively (application of CPAP during nighttime), while the second required emergency intubation and a combined ENT-neurosurgical operation for the removal of osteophytes. Clinical Relevance: Even though dysphagic symptoms are more frequent, DISH may be a cause of airway obstruction and should be included in the differential diagnosis of respiratory distress and OSA.

OBJECTIVE: Drug-induced sedation endoscopy (DISE) classification systems have been used to assess anatomical findings on upper airway obstruction, and decide and plan surgical treatments and act as a predictor for surgical treatment outcome for obstructive sleep apnoea management. The first objective is to identify if there is a universally accepted DISE grading and classification system for analysing DISE findings. The second objective is to identify if there is one DISE grading and classification treatment planning framework for deciding appropriate surgical treatment for obstructive sleep apnoea (OSA). The third objective is to identify if there is one DISE grading and classification treatment outcome framework for determining the likelihood of success for a given OSA surgical intervention.
METHODS: A systematic review was performed to identify new and significantly modified DISE classification systems: concept, advantages and disadvantages.
RESULTS: Fourteen studies proposing a new DISE classification system and three studies proposing a significantly modified DISE classification were identified. None of the studies were based on randomised control trials.
CONCLUSIONS: DISE is an objective method for visualising upper airway obstruction. The classification and assessment of clinical findings based on DISE is highly subjective due to the increasing number of DISE classification systems. Hence, this creates a growing divergence in surgical treatment planning and treatment outcome. Further research on a universally accepted objective DISE assessment is critically needed.

OBJECTIVE: Herpes simplex virus (HSV) laryngitis is rare in adults. We add a case report to the literature and perform a literature review to further delineate the clinical presentation, course, and treatment of HSV laryngitis in adults.
METHODS: Case report and literature review using PubMed and Ovid databases.
RESULTS: Ten cases of diagnosed HSV laryngitis in adults were reported in the literature. It is more common in immunocompromised patients. The mean patient age was 51 years with a male to female ratio of 1:1. The clinical presentation and course of HSV laryngitis is variable. Patients may have mild chronic symptoms, such as dysphonia, or a fulminant course with rapid airway compromise. On laryngoscopic exam, the most common findings are a white exudate or ulceration. The most common treatment is with antiviral medication, such as acyclovir, which tends to be highly effective.
CONCLUSIONS: Herpes simplex virus laryngitis is rare. Clinical presentation of HSV laryngitis is variable, and its course may be indolent or fulminant. Treatment with antiviral medication tends to be highly effective.

Hypothyroidism has been associated with increased pulmonary morbidity and overall mortality. A systematic review was conducted to identify the prevalence and underlying mechanisms of respiratory problems among patients with thyroid insufficiency.
PubMed and EMBASE databases were searched for relevant literature from January 1950 through January 2015 with the following study eligibility criteria: English-language publications; adult subclinical or overt hypothyroid patients; intervention, observational, or retrospective studies; and respiratory manifestations. The Preferred Reporting Items for Systematic reviews and Meta-Analyses statement was followed, and Cochrane\'s risk of bias tool was used.
A total of 1699 papers were screened by two independent authors for relevant titles. Of 109 relevant abstracts, 28 papers underwent full-text analyses, of which 22 were included in the review. Possible mechanisms explaining respiratory problems at multiple physiological levels were identified, such as the ventilator control system, diaphragmatic muscle function, pulmonary gas exchange, goiter caused upper airway obstruction, decreased capacity for energy transduction, and reduced glycolytic activity. Obstructive sleep apnea syndrome was found among 30% of newly diagnosed patients with overt hypothyroidism, and demonstrated reversibility following treatment. The evidence for or against a direct effect on pulmonary function was ambiguous. However, each of the above-mentioned areas was only dealt with in a limited number of studies. Therefore, it is not possible to draw any strong conclusions on any of these themes. Moreover, most studies were hampered by considerable risk of bias due for example to small numbers of patients, lack of control groups, randomization and blinding, and differences in body mass index, sex, and age between subjects and controls.
Mechanistic data linking hypothyroidism and respiratory function are at best limited. This area of research is therefore open for retesting hypotheses, using appropriate study designs and methods.