SummaryFifty female patients were studied to compare the view of the larynx at direct laryngoscopy under general anaesthesia with and without cricoid pressure applied. We also compared the view using the standard technique of cricoid pressure with that using cricoid pressure in an upward and backward direction and further investigated whether these views were improved with a firm foam rubber neck support. The order in which the types of cricoid pressure were applied was randomised and also blinded with a drape over the neck. Cricoid pressure was simulated on weighing scales after each case and a mean force of 3.2 kg was applied. The majority of views at laryngoscopy (95%) were grade 1, with too few grade 2 and 3 views for statistical comparison. Both types of cricoid pressure applied without neck support were more likely to give a better view than no cricoid pressure (p < 0.01) and cricoid pressure in an upward and backward direction was more likely to give a better view at laryngoscopy than the standard technique (p < 0.01). Neck support during the standard technique of cricoid pressure did not improve the view of the larynx at laryngoscopy. Cricoid pressure is likely to improve the view at laryngoscopy which may be further improved by applying it in an upward and backward direction.Keywords Larynx; cricoid pressure. Intubation; tracheal. ...................................................................................... Correspondence to: R. G. Vanner Accepted: 17 February 1997 Cricoid pressure is routinely used to prevent regurgitation of gastric contents into the pharynx during the induction of general anaesthesia in all the Maternity Units recently surveyed in the UK [1]. However, it has been suggested that the use of cricoid pressure may make tracheal intubation more difficult [2, 3]. It is not clear whether poor technique alone is responsible or whether correctly applied cricoid pressure may also cause difficulty with intubation. Although it is well known that a degree of pressure on the front of the larynx can improve the view at laryngoscopy [4] it is not known whether correctly applied cricoid pressure, at a force that would prevent regurgitation, alters the view at laryngoscopy.Neck support has been recommended to improve the view at laryngoscopy during the application of cricoid pressure by preventing the head flexing on the neck, either with a bimanual technique [5] or with a cuboid of foam rubber [6]. Bimanual cricoid pressure has been adopted widely [1, 7] despite the lack of evidence supporting this hypothesis; indeed one recent study showed no improvement in the view at laryngoscopy when comparing bimanual with single handed cricoid pressure [8].If the arch of the cricoid cartilage is pushed in an upward (cephalad) direction [9], or the whole larynx is moved in an upward direction [10, 11], the view at laryngoscopy is improved compared with the view with no external manipulation. Therefore, cricoid pressure applied in an upward and backward direction with enough force to prevent reg...

DIN is a mild form of LC1 and is considered a normal anatomical variant. Recent cohort studies demonstrate IL to be a safe, low-risk, and efficacious treatment of LC1, but few studies focus on DIN. We present results from two aerodigestive clinic (ADC) pilot studies at our institution, in patients 1-3 years old, with DIN-related dysphagia and aspiration (DA). Feeding, respiratory-related symptom scores, and aspiration/penetration assessed on modified barium swallow (MBS) significantly improved following combined IL and feeding therapy using a thickener weaning protocol (TWP). Subgroup analysis reveals combined IL and TWP to be particularly effective in patients with severe baseline DA. Multidisciplinary aerodigestive evaluation and management with IL and feeding therapy focused on weaning levels of thickener is emerging as a novel and effective approach for treatment of DIN-related DA in young children. Further comparative, prospective trials investigating effects of IL and feeding therapy are required to validate results.

Objectives: Deep interarytenoid notch (DIN) is a congenital variation of the larynx often associated with dysphagia and aspiration (DA) in young children. Feeding therapy with thickeners and surgical management with injection larygoplasty (IL) are used with various efficacies. Thickeners address the functional domain and IL addresses the anatomical domain of treatment. Our objective was to evaluate DIN patients managed with both interventions. Methods: We conducted a retrospective pilot descriptive study of DIN patients with DA aged 1-3 years receiving thickeners and IL. Patients received a systematic weekly reduction of thickeners based on clinical signs and symptoms of DA. The outcomes were assessed by the rate of thickener level reduction and DA-related sign/symptom frequency achieved at 6 months post-treatment.Results: Thirteen patients with DIN associated DA were analyzed. Thickener scores improved from an average of 5.76 (3/4 honey) to 2.15 (thin) (p = 0.001). DA-related signs/symptoms frequency improved from an average of 3.3 to 0.84 (p = 0.05).Conclusions: These findings suggest that treatment of DIN associated DA with a combination of thickeners and IL results in significant clinical improvements in young children.