Background Patients suffering from undiagnosed obstruction of the central airways: the trachea and main stem bronchi are at increased risk for perioperative and postoperative complications, especially if general anesthesia is performed. Case Description This report discusses a 30-year-old asymptomatic Caucasian female who faced recurrent distal airway collapse during mediastinoscopy for biopsy of an anterior mediastinal mass, which led to the inability to extubate her. This case examines the necessity of a thorough preoperative assessment especially in patients with undiagnosed tracheal obstruction and a precise coordination between anesthesiologist and surgeon in being able to perform a safe and smooth anesthesia, in order to avoid life-threatening complications and to reduce further morbidity. Methods The scope of this case report is restricted to publications in all surgical and anesthesiological specialties among adult patient population. Main search key words were as follows: “tracheal obstruction,” “general anesthesia,” “mediastinum,” and “tumors” Results. The literature supports an increased perioperative risk of airway obstruction with the use of general anesthesia in patients with anterior mediastinal masses. This case report suggests a perioperative anesthetic management modality for patients presenting with anterior mediastinal masses and who are at high risk of cardiovascular compression and tracheal obstruction. Thus, it is highly important to note that evidence-based recommendations are not available in the literature. Conclusions This case report suggests perioperative management modalities performed by anesthesiologists in order to minimize the risk of airway obstruction among patients having anterior mediastinal masses and shed the lights on the importance of proper anesthetic and surgical planning in order to prevent intraoperative complications and improve the quality of healthcare provided to patients presenting critical cases.

Children presenting with ingestion of foreign bodies need gastroscopy as a primary management modality. A controversy lies regarding guidelines for preoperative fasting among children with low risk of aspiration and intraoperative complications. This case report represents cases of children who ingested foreign bodies and underwent fasting at different times preoperatively. With mounting evidence questioning the benefits of long durations of fasting in decreasing the risk of aspiration and with studies showing that fasting for more than 2 hours after ingestion of clear fluid does not significantly alter gastric pH or volume, these incidental findings raise the question of whether it is safe to keep children NPO, for a shorter duration before the administration of anesthesia. In addition, this report shows that current guidelines are in need of revision.

In a surgical setting, intraoperative methylene blue usage is a safe and effective technique in detecting gastric leak during laparoscopic abdominal surgery [1]. A Nasogastric (NG) tube is commonly used to empty the stomach and to monitor the occurrence of bowel occlusion after major abdominal surgery. The incidence of misplacement of NG tubes into the airways ranges between 0.3% and 15% [2] and is associated with significant morbidity and mortality [3]. A 68-year-old male patient presented to the operating room for scheduled laparoscopic cholecystectomy. After tracheal intubation and commencement of surgery, an 18 Fr. NG tube was inserted blindly through the nostril with no means of assessing its position. A solution of methylene blue was prepared and 240 ml were injected in the NG tube. Upon applying negative pressure suction on the NG, a noticeable change in airway pressure was noted and investigation through the use of fiber optic vision revealed the presence of bluish liquid in the bronchi. The NG tube was then re-inserted, the surgeon made the final confirmation of its proper placement within the stomach and the surgery continued uneventfully. Postoperative chest x-ray was suggestive of hypersensitivity pneumonitis and emphysema. Patient was first admitted to the intensive care unit where treatment was initiated, to be then transferred to the ward and later discharged on post-operative day three. Keywords: laparoscopic cholecystectomy; methylene blue; nasogastric tube; hypersensitivity pneumonitis; emphysema.

Oxygen-ozone therapy is a minimally invasive treatment for disc herniation, compared to surgery, which uses the beneficial biochemical properties of a gas mixture of ozone and oxygen. A satisfactory efficacy is usually obtained within one month after the injection. We assessed the therapeutic outcome of a single injection of oxygen-ozone in a symptomatic patient with C5-C6 cervical discal herniation with compression of the nerve roots. He experienced immediate pain relief seconds after the injection, and neuro-imaging improvement 24 hours afterwards. To our knowledge this is the fastest improvement ever reported in literature.

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