BACKGROUND: Ohtahara syndrome is a progressive developmental and epileptic encephalopathy that manifests in the early infantile period. This rare condition is characterized by intractable seizures, psychomotor retardation, and poor prognosis. To date, there are a handful of case reports regarding the anesthetic management of children with Ohtahara syndrome. However, limited reports exist of patients with Ohtahara syndrome who present with difficult airways. This report describes our airway findings and general anesthetic management of a pediatric patient with Ohtahara syndrome undergoing diagnostic bronchoscopy for severe inspiratory stridor.
METHODS: A 14-month-old, 9 kg, male patient with Ohtahara syndrome presented with a year-long history of severe inspiratory stridor and was scheduled for bronchoscopy with lavage. On exam, the patient had noisy breathing, was non-verbal with developmental delay, and had poor head control with significant central hypotonia. The patient was induced with ketamine and general anesthesia was maintained with propofol. Bronchoscopic evaluation was completed uneventfully and revealed a diagnosis of laryngotracheomalacia. The patient\'s breathing was maintained spontaneously throughout the procedure and no seizures were noted. In the post anesthesia care unit, the patient\'s respiratory and cardiovascular function were stable.
CONCLUSIONS: This report documents the unusual finding of severe inspiratory stridor in a 14-month-old child diagnosed with Ohtahara syndrome and our anesthetic management during their diagnostic bronchoscopy. Currently, documentation of complex airway pathology present in patients with Ohtahara syndrome is limited and should be further evaluated. This will assist pediatric anesthesiologists as these patients may require careful preoperative assessment, thoughtful airway management, and surgical alternatives on standby.

BACKGROUND: Gossypiboma, a retained surgical sponge with a foreign body reaction, is an unusual but serious complication seen in open abdominal surgeries. It is exceptionally rare following head and neck surgeries. Here, we present a case of Gossypiboma of the upper airway following tracheostomy.
METHODS: A 32-year-old male presented with stridor and difficulty breathing one-month post-tracheostomy after a severe head injury following a road traffic accident. A neck radiograph was unremarkable, and a computed tomography (CT) scan of the neck showed a well-defined homogenous curvilinear membrane extending from the hypopharynx to the upper trachea. Bronchoscopic evaluation of the larynx and upper trachea revealed a retained surgical sponge, which was retrieved. The patient\'s breathing improved drastically post intervention.
CONCLUSIONS: Gossypiboma may go undetected in radiographs and may also present atypically as a homogenous membrane on a CT scan of the neck. Though rare, retained surgical items can have profound medicolegal and professional consequences on physicians. Hence, a strong clinical suspicion and vigilance for gossypiboma is necessary for patients presenting with respiratory distress post-tracheostomy.

This case report details an atypical etiology of laryngotracheitis (croup) in a three-year-old child diagnosed with coronavirus disease 2019 (COVID-19). Unlike typical croup cases, the patient required hospitalization and multiple administrations of racemic epinephrine for respiratory distress. The author highlights the importance of considering COVID-19 (severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) as a potential etiology of croup in children. This distinction is crucial as such cases may necessitate more intensive medical intervention and prolonged monitoring compared to standard croup treatment protocols. The patient reported here did not require intensive care admission or respiratory support.

The authors report a case of circumflex aorta causing persistent respiratory distress in a 9-year-old boy who had previously undergone vascular ring division and multiple aortopexies. The uncrossing operation was performed, with symptomatic relief of both posterior and right-sided tracheal compression from the transverse aorta and right aortic arch, respectively.

IgG4 related disease (IgG4-RD) is a multisystem inflammatory disease and can affect several organs including salivary glands, orbits, lungs, pancreas, kidneys and lymph nodes. Up to 40 % of patients have allergic manifestations including asthma, chronic rhinosinusitis, eczema and asthma. Commonly pulmonary manifestations include pulmonary nodules ranging from <1 to 5 cm in diameter, interstitial opacities and mediastinal lymphadenopathy. Rarely, IgG4-RD presents as isolated tracheal disease. Symptoms include dyspnea and stridor due to airway narrowing. Diagnosis of IgG4-RD including tracheal IgG4-RD requires a biopsy. The histologic specimen is characterized by lymphoplasmacytic infiltrate with high density of IgG4 positive plasma cells, and storiform fibrosis (a cartwheel appearance of fibroblasts and inflammatory cells). Up to 30 % of patients with IgG4-RD have normal serum IgG4 levels. The mainstay of therapy is glucocorticoids for those with systemic disease. Rituximab is an alternative for those who cannot tolerate glucocorticoids or those with disease recurrence. Patients with tracheal disease often require balloon dilation. Recurrence is common in patients and up to two thirds of patients have residual disease despite treatment. These patients often require surgical resection of affected area for symptomatic relief.

A vallecular cyst is a rare diagnosis in newborns presented with stridor, which poses a significant threat to the well-being of infants. This potentially life-threatening condition is associated with a range of complications, including respiratory distress, feeding difficulties, and failure to thrive. Through this case series, we aim to shed light on the suspicion of vallecular cysts in newborns presenting with stridor and the complexities encountered during their management, highlighting the importance of early recognition and intervention. We presented a case series consisting of three newborns who presented with stridor and respiratory distress symptoms to our center. All three cases were diagnosed using a flexible laryngoscope, and surgical intervention was done. The vallecular cyst was removed, and subsequent follow-up showed no recurrence of the lesion. This case series highlights the importance of early suspicion and recognition of vallecular cysts in newborns, emphasizing the thorough examination during diagnostic evaluations. Proper surgical planning and appropriate ventilation strategies are essential for the successful management and resolution of symptoms.

OBJECTIVE: Occurrence of post-intubation laryngotracheal stenosis (LTS) with respect to COVID-19 status.
METHODS: Retrospective cross-sectional inpatient database.
METHODS: Eleven Midwest academic and community hospitals, United States.
METHODS: Adults, mechanically ventilated, from January 2020 to August 2022, who were subsequently readmitted within 6 months with a new diagnosis of LTS.
METHODS: None.
RESULTS: Six thousand eight hundred fifty-one COVID-19 negative and 1316 COVID-19 positive patients were intubated and had similar distribution by age (median 63.77 vs. 63.16 yr old), sex (male, 60.8%; n = 4173 vs. 60%; n = 789), endotracheal tube size (≥ 7.5, 75.8%; n = 5192 vs. 75.5%; n = 994), and comorbidities. The ICU length of stay (median [interquartile range (IQR)], 7.23 d [2.13-16.67 d] vs. 3.95 d [1.91-8.88 d]) and mechanical ventilation days (median [IQR], 5.57 d [1.01-14.18 d] vs. 1.37 d [0.35-4.72 d]) were longer in the COVID-19 positive group. The occurrence of LTS was double in the COVID-19 positive group (12.7%, n = 168 vs. 6.4%, n = 440; p < 0.001) and was most commonly diagnosed within 60 days of intubation. In multivariate analysis, the risk of LTS increased by 2% with each additional ICU day (hazard ratio [HR], 1.02; 95% CI, 1.02-1.03; p < 0.001), by 3% with each additional day of ventilation (HR, 1.03; 95% CI, 1.02-1.04; p < 0.001), and by 52% for each additional reintubation (HR, 1.52; 95% CI, 1.36-1.71; p < 0.001). We observed no significant association COVID-19 status and risk of LTS.
CONCLUSIONS: The occurrence of post-intubation LTS was double in a COVID-19 positive cohort, with higher risk with increasing number of days intubated, days in the ICU and especially with the number of reintubations. COVID-19 status was not an independent risk factor for LTS.

Cystic hygroma of the neck, a congenital benign tumor of the lymphatic system, is a potential cause of neonatal airway obstruction leading to stridor. Meticulous airway evaluation, case appropriate preparation, and use of advanced technology, including videolaryngoscope and ultrasonography, can facilitate the safe management of the difficult airway.

Diffuse large B-cell lymphoma, primarily nodal in nature, can present with rare endobronchial involvement, underscoring the importance of considering it in the differential diagnoses of endobronchial lesions.

Epiglottic cysts are benign lesions of the larynx that are relatively rare beyond infancy age. A 17-year-old adolescent male patient presented to the outpatient specialized oropharyngeal clinic with inspiratory stridor, chronic sore throat, and progressive dyspnea symptoms over the past eight months. Examination by a headlight and a tongue depressor showed a large cystic lesion arising from the hypopharynx. A neck computed tomography (CT) scan revealed a 4 cm oval cyst attached to the lingual epiglottic surface. The relatively large epiglottic cyst was drained directly in the clinic and was later removed by microlaryngosurgery with traditional microinstrumentation in a follow-up visit. Subsequent recovery was uneventful. Regardless of the rarity of epiglottic cysts in adolescents, doctors should keep in mind this etiology as early diagnosis and management could spare the patient from life-threatening complications or tracheostomy and unneeded medical costs.