The Hunsaker Mon-Jet ventilation tube for microlaryngeal surgery: optimal laryngeal exposure. (Original Article).Abstract Methods of delivering and monitoring anesthesia during microlaryngeal surgery are constantly evolving. In 1994, Hunsaker and colleagues introduced a laser-safe subglottic Mon-Jet ventilation tube, which has the ability to periodically measure end-tidal carbon dioxide carbon dioxide, chemical compound, CO2, a colorless, odorless, tasteless gas that is about one and one-half times as dense as air under ordinary conditions of temperature and pressure. levels. We conducted a retrospective review of 84 consecutive patients who had undergone microlaryngeal procedures with the aid of the Hunsaker Mon-Jet tube. Study parameters included the length of anesthetic induction and recovery times, the duration of surgery, the degree of surgical access to the larynx, and the incidence of anesthetic and surgical complications. We found that anesthetic induction and recovery times with the use of the Mon-Jet tube were comparable to those seen with standard endotracheal intubation. We also observed an apparent reduction in surgical time and a consistent subjective improvement in surgical visualization and access. The complication rate was acceptable, airway control was adequate, and use of the Mon-Jet tube wa s safe in all patients. We conclude that the Mon-Jet tube is a safe and effective subglottic jet ventilation system and that it has distinct advantages over other methods for both the surgeon and the anesthesiologist Anesthesiologist A medical specialist who administers an anesthetic to a patient before he is treated. Mentioned in: Anesthesia, General, Appendectomy, Parathyroidectomy anesthesiologist . Introduction Although suspension microlaryngeal surgical techniques have advanced significantly during the past 30 years, the safest and least obtrusive ob·tru·sive adj. 1. Thrusting out; protruding: an obtrusive rock formation. 2. Tending to push self-assertively forward; brash: a spoiled child's obtrusive behavior. method of delivering anesthesia during these procedures has not yet been determined. (1-4) From the surgeon's perspective, an optimal system would permit complete visual and surgical access to the endolarynx without impeding surgical manipulation, moving the vocal folds, or allowing blood, tissue, or laser fumes fumes odorous gases and other volatile materials; inhalation of irritating fumes causes coughing and, if sufficiently severe, irreversible pulmonary edema. to enter the bronchi bronchi /bron·chi/ (brong´ki) plural of bronchus. Bronchi Two main branches of the trachea that go into the lungs. This then further divides into the bronchioles and alveoli. . From the anesthesiologist's perspective, the ideal system would allow for control of ventilation and the airway and monitoring of the patient's physiologic response to the operation by measuring tracheal tracheal pertaining to or emanating from trachea. tracheal aspiration see transtracheal aspiration. tracheal band sign on contrast radiography of a dilated esophagus, the impression made ventrally by the trachea. pressure and end-tidal carbon dioxide ([ETCO ETCO European Transplant Coordinators Organization ETCO Emergency Traffic Coordinating Officer ETCO Electric Terminal Company Ltd (Korea) .sub.2]) levels. Among the different options that have been tried are topical and apneic anesthesia, diffusion respiration, spontaneous respiration, laser-shielded endotracheal intubation, and sub- and supraglottic jet ventilation. Most of these procedures have significant limitations. (5) In 1994, Hunsaker and colleagues introduced a fluoroplastic, laser-safe, self-centering, subglottic jet ventilation device: the Hunsaker Mon-Jet tube (Xomed Surgical Products; Jacksonville, Fla.). (6) This tube allows for the continuous monitoring of end-expiratory and peak airway pressures, as well as periodic sampling of [ETCO.sub.2] levels. The first clinical study of the Hunsaker Mon-Jet tube found that it was successful in 36 patients who had undergone microlaryngeal surgery. (5) Our study was a retrospective review of 84 patients who underwent microlaryngeal procedures with the aid of the Mon-Jet tube. Study parameters included the length of anesthetic induction and recovery times, the duration of surgery, the degree of surgical access to the larynx, and the incidence of anesthetic and surgical complications. Materials and methods After our protocol was approved by the Institutional Review Board at the University of California, San Diego UCSD is consistently ranked among the top ten public universities for undergraduate education in the United States by U.S. News & World Report.[3] It is a Public Ivy. [1] For graduate studies, most of UCSD's Ph.D. Medical Center, we reviewed the records of 84 consecutive patients who had undergone suspension microlaryngeal surgery with the aid of the Mon-Jet tube between September 1992 and July 1999. All operations were conducted by the same faculty surgeon (L.A.O.) with assistance from a surgical resident. All procedures were performed with either an adult Jako, Hollinger, or Dedo laryngoscope. Anesthesia was administered by either an anesthesiology resident or a certified registered nurse anesthetist with the oversight of a faculty anesthesiologist. The anesthetic process included manual jet ventilation with the Hunsaker Mon-Jet tube. The Mon-Jet subglottic jet ventilation device is 35.5 cm long and is curved to facilitate insertion (figure 1). The maximum outer diameter of the .jet monitor port is 4.3 mm, and the internal diameter is 2.7 mm. The tube is self-centering in the trachea trachea (trā`kēə) or windpipe, principal tube that carries air to and from the lungs. It is about 4 1-2 in. (11.4 cm) long and about 3-4 in. (1.9 cm) in diameter in the adult. ; a basket-shaped distal extension prevents malalignment and keeps the jet port from coming into contact with the tracheal mucosa (figure 2). The device is made entirely of a nonflammable non·flam·ma·ble adj. Not flammable, especially not readily ignited and not rapidly burned. fluoroplastic material that is laser safe. (7) The tube contains a monitor port (internal diameter: 1 mm) that is attached proximally to a Leur-Loc adapterthatopens 3.2cm above the jet port. Anautomatic ventilator can be attached that allows for continuous monitoring of tracheal pressure and intermittent monitoring of the [ETCO.sub.2] level. Ventilation and intermittent [ETCO.sub.2] measurement can also be performed manually, as was done in this study. The distal end of the tube was placed at least 5 cm below the glottis glottis /glot·tis/ (glot´is) pl. glot´tides [Gr.] the vocal apparatus of the larynx, consisting of the true vocal cords and the opening between them.glot´tal glot·tis n. pl. , which ensured that the monitor port was below the vocal folds. The tube was secured at the corner of the mouth (figure 3). At the end of the procedure, emergence from anesthesia was accomplished with a masked airway. Results The 84 cases included 49 [CO.sub.2] laser operations, 27 excisions or biopsies of vocal fold lesions, and eight vocal fold injections with Gelfoam. Intraoperative photographs were taken to document surgical exposure (figure 4). Anesthetic induction and recovery. The time required for anesthetic induction ranged from 5 to 30 minutes. The time required for patient recovery also ranged from 5 to 30 minutes. Recovery from anesthesia was achieved via a masked airway. Reintubation with a standard endotracheal tube was performed on one patient who had experienced prolonged neuromuscular relaxation; the decision to reintubate was based on the preference and comfort level of the staff anesthesiologist, and was not done as the result of any complication. Duration of surgery. The duration of surgery ranged from 15 minutes to 1 hour and 40 minutes (mean: 41 min). Surgical access. There was no instance of an impairment of surgical manipulation or a need for Mon-Jet tube repositioning to improve access to the endolaryax during any of the 84 procedures. Complications. There were no instances of barotrauma barotrauma /baro·trau·ma/ (-traw´mah) injury due to pressure, as to structures of the ear, in high-altitude flyers, owing to differences between atmospheric and intratympanic pressures; see barosinusitis and barotitis. , submucosal submucosal /sub·mu·co·sal/ (-mu-ko´sal) 1. pertaining to the submucosa. 2. beneath a mucous membrane. injection of jetted gas, gastric distention dis·ten·tion or dis·ten·sion n. The act of distending or the state of being distended. distention, n a state of dilation. , mucosal damage, seeding of blood or debris into the tracheobronchial tracheobronchial /tra·cheo·bron·chi·al/ (-brong´ke-al) pertaining to the trachea and bronchi. tra·che·o·bron·chi·al adj. Of or relating to the trachea and the bronchi. tree, or tube ignition in any of the 84 cases. One case of accidental extubation occurred; following reintubation, the remainder of the procedure was uneventful. One case of laryngospasm was observed during emergence from anesthesia after the Mon-Jet tube had been withdrawn. The spasm was managed successfully with masked ventilation, a deepening of the anesthesia, and the use of intravenous lidocaine lidocaine /li·do·caine/ (li´do-kan) an anesthetic with sedative, analgesic, and cardiac depressant properties, applied topically in the form of the base or hydrochloride salt as a local anesthetic; also used in the latter form as a , and the patient re-emerged from anesthesia uneventfully. The Mon-Jet tube was used in patients who were classified according to criteria established by the Amenan Society of Anesthesiologists (ASA Asa (ā`sə), in the Bible, king of Judah, son and successor of Abijah. He was a good king, zealous in his extirpation of idols. When Baasha of Israel took Ramah (a few miles N of Jerusalem), Asa bought the help of Benhadad of Damascus and ) as either type I, type II, or type III. The ASA classification system provides a general indication of a patient's overall wellbeing. The scale ranges from I (stable and healthy) to VI (unstable and/or ill). The Mon-Jet tube was found to be safe in all 84 patients, including 11 ASA type III patients. This was the first clinical study of the use of the Mon-Jet tube in ASA type III patients. Gas and pressure monitoring. Intermittent sampling revealed that [ETCO.sub.2] levels ranged from 26 to 32 mm Hg. The corrected level of partial arterial [CO.sub.2] pressure ([PaCO.sub.2]) was with the normal range of 36 to 44 mm Hg at sea level. Oxygen ([O.sub.2]) saturation was measured via pulse oximetry; the lowest [O.sub.2] saturation level was 95%. Discussion The optimal system for general anesthesia during suspension laryngoscopy would allow the surgeon complete and unimpeded access to the endolarynx without vocal fold movement. It would also provide the anesthesiologist with total control of the airway and the ability to measure [ETCO.sub.2] levels and monitor the patient's physiologic response to the operation. Many techniques have been developed in an effort to achieve this ideal. (6) For example, the use of wrapped standard endotracheal tubes, including silicone tubes wrapped with fluoroplastic tape, has been tried in order to provide laser safety; however, these tubes significantly limit the exposure to the larynx, especially the interary-tenoid recess. (7) Another approach involves supraglottic jet ventilation with a rigid metal tube fixed to the suspended laryngoscope. With this technique, [O.sub.2] is jetted through the vocal folds. Although supraglottic jet ventilation provides excellent surgical exposure, it carries the risk of causing gastric distention as a result of high pressures and malalignment, inefficient or inefficient or ineffective ventilation, the blowing of blood and debris into the bronchi, vocal fold movement with ventilation, and an inability to monitor airway pressure. (8) Subglottic jet ventilation has three potential advantages: (1) It allows for excellent ventilation and airway control, (2) it is not associated with the blowing of blood and debris into the distal tracheobronchial tree, and (3) it does not impede surgical access. Nevertheless the original application of this technique was associated with baotrauma as a result of a proximal obstruction of the expiration of jetted gas. (6) In 1979, Benjamin and Gronow fashioned a small polyvinyl chloride tube for insertion into the subglottic trachea that had four petals on the distal end. (9) These petals ensured that the tube would be centered in the trachea, which decreased the risk of malalignment, displacement, and submucosal injection of jetted gas. Because this tube was small, it also allowed the surgeon complete and unimpeded access to the endolarynx. However, this device was not laser resistant, and it did not allow for the monitoring of tracheal pressure and [ETCO.sub.2] levels. Hunsaker improved Benjamin and Gronow's tube by adding a side port to facilitate the monitoring of tracheal pressure and [ETCO.sub.2]. (6,10). He also made the tube laser-compatible by constructing it from a nonflammable fluoroplastic material. The safety of this material was confirmed after it was subjected to [CO.sub.2], KTP KTP Knowledge Transfer Partnership KTP Potassium Titanyl Phosphate KTP Kartu Tanda Penduduk (Indonesian ID card) KTP Kaj Tiel Plu (Esperanto: Et Cetera) KTP KTiOPO4 (potassium-titanyl-phosphate), and Nd:YAG (neodymium neodymium (nē'ōdĭm`ēəm), metallic chemical element; symbol Nd; at. no. 60; at. wt. 144.24; m.p. about 1,021°C;; b.p. about 3,068°C;; sp. gr. 7.004 at 20°C;; valence +3. Neodymium is a lustrous silver-yellow metal. :yttrium-aluminum-garnet) lasers at maximum output in a 100% [O.sub.2] environment. (6) From the surgeon's perspective, one of the most significant subjective advantages of the Mon-Jet system is the exposure it allows to the larynx. Visualization of the larynx is unimpeded, and the surgeon can easily manipulate the glottic glot·tic adj. 1. Of or relating to the tongue. 2. Of or relating to the glottis. glottic pertaining to (1) the glottis, or (2) the tongue. and supraglottic structures. [CO.sub.2] laser surgery, vocal fold lesion excisions, and phonosurgical operations can be performed with less need to reposition the laryngoscope or endotracheal tube during the procedure. Owing to good surgical exposure, we observed a subjective reduction in the duration of surgery with the Mon-Jet tube (mean: 41 min). A major concern with subglottic jet ventilation is the risk of proximal obstruction of expiration, which can result in excessive intratracheal pressure and cause pneumomediastinum or pneumothorax pneumothorax (n  mōthôr`ăks), collapse of a lung with escape of air into the pleural cavity between the lung and the chest wall. The cause may be traumatic (e.g. . (11) With the Mon-Jet system, the monitor port allows for continuous pressure measurements; also, the ventilator can be programmed to automatically shut off if pressure exceeds an unacceptable level. Although manual rather than automatic jet ventilation was administered to all of our 84 patients, we observed no instances of pneumothorax or any other signs of barotrauma. Barotrauma with resultant pneumothorax has been reported with both transtracheal and translaryngeal jet ventilation. (12, 13) Similar complications can occur following [O.sub.2] jet ventilation via a Cook airway-exchange catheter (Cook Critical Care; Elletsville, Ind.). (14) Passing a high-pressure [O.sub.2] jet through a narrow orifice orifice /or·i·fice/ (or´i-fis)1. the entrance or outlet of any body cavity. 2. any opening or meatus.orific´ial aortic orifice creates a Venturi effect and results in air entrapment entrapment, in law, the instigation of a crime in the attempt to obtain cause for a criminal prosecution. Situations in which a government operative merely provides the occasion for the commission of a criminal act (e.g. and a marked increase in the total flow. (15, 16) The smaller the cross-sectional area of the endotracheal tube, the higher the resistance to exhalation exhalation /ex·ha·la·tion/ (eks?hah-la´shun) 1. the giving off of watery or other vapor. 2. a vapor or other substance exhaled or given off. 3. the act of breathing out. . [O.sub.2] jet ventilation delivered via the lumen of the catheter can result in barotrauma and tension pneumothorax. (17) In such a case, barotrauma occurs when the volume of air entry exceeds that of air exit. The risk of barotrauma during jet ventilation can be reduced by minimizing airway pressure and prolonging expiratory ex·pi·ra·to·ry adj. Of, relating to, or involving the expiration of air from the lungs. expiratory relating to or employed in the expiration of air from the lungs. time. Barotrauma can also be prevented by slowing the flow of [O.sub.2] (1 to 2 L/min) through the lumen of the exchange catheter or through the Mon-Jet tube. (18) By setting the jet ventilator pressure to 25 pounds per square inch Noun 1. pounds per square inch - a unit of pressure psi pressure unit - a unit measuring force per unit area (psi) or less and by limiting inspiratory in·spi·ra·to·ry adj. Of, relating to, or used for the drawing in of air. inspiratory pertaining to or used in the inspiration of air into the lungs. time to less than 1 second, it is possible to provide life-sustaining ventilatory support without increasing the risk of barotrauma. (18,19) In our study, the maximum pressure was 30 psi and the maximum inspiratory time was I second. Because the distal end of the Mon-Jet tube lies 5 cm or more below the vocal folds and a steady flow of air passes upward through the glottis, the only material that could blow beyond the tube and into the bronchi would be from a massive bleed. (9,10) Unlike supraglottic jetting, in which blood and tissue can be blown distally and require treatment suction, (20) the Mon-Jet tube requires little, if any, suctioning. In none of our 84 cases did blood or tissue reach the distal end of the jet tube. From the anesthesiologist's perspective, the Mon-Jet tube provides adequate ventilation, does not lengthen the time needed to induce anesthesia, and does not increase the risk of anesthetic complications. Gaughan et al reported that jet ventilation through all sizes of tube exchangers can provide effective ventilation. (19) The Mon-Jet tube is comparable to the smaller airway-exchange catheters in terms of its internal diameter and its ability to adequately ventilate ventilate, v 1. to provide with fresh air. v 2. to provide the lungs with air from the atmosphere. v 3. to open, to free, as in to openly express one's feelings. . The time required for anesthetic induction and recovery in our study ranged from 5 to 30 minutes, which is comparable to that seen with standard endotracheal intubation. It appears that the length of time is a function of the anesthesiologist's ability and experience and the patient's status and airway grade rather than the type of tube that is used. Admittedly, manual jet ventilation is more labor-intensive than is automatic ventilation with standard endotracheal intubation. All patients in our study were administered manual jet ventilation. However, since we completed our review, we have switched to using an automatic jet ventilator with the Mon-Jet tube. The automatic ventilator has considerably simplified the demands on the anesthetists and maximized the use of the device itself. [ETCO.sub.2] as reliable a means of monitoring ventilation status as is the measurement of serial [PaCO.sub.2] by arterial blood gas arterial blood gas Critical care Analysis of arterial blood for O2, CO2, bicarbonate content, and pH, which reflects the functional effectiveness of lung function and to monitor respiratory therapy Ref range pO2 . (21) Measurement of [ETCO.sub.2] levels is the standard of care for monitoring minute ventilation. [ETCO.sub.2] is the [CO.sub.2] content in the final gas exhaled from the lungs for a given breath, and it is measured by spectrophotometry spectrophotometry Branch of spectroscopy dealing with measurement of radiant energy transmitted or reflected by a body as a function of wavelength. The measurement is usually compared to that transmitted or reflected by a system that serves as a standard. or by mass spectrometry. The [CO.sub.2] exhaled from the alveoli Alveoli Small air sacs or cavities in the lung that give the tissue a honeycomb appearance and expand its surface area for the exchange of oxygen and carbon dioxide. mixes with and is diluted by gas from the conducting airways and the breathing circuit that was not involved in gas exchange. Because exhaled [CO.sub.2] is diluted, the [ETCO.sub.2] level is usually lower than the [PaCO.sub.2] level; in healthy lungs, it is usually 5 cm lower. The difference between the two levels becomes even greater with increasing dead-space ventilation, which is often reported during the use of airway-exchange catheters, high-frequency jet ventilators, and manual jet ventilators. (22) In our study, ET[CO.sub.2] levels ranged from 26 to 32 mm Hg and Pa[CO.sub. 2] levels were within the normal range of 36 to 44 mm Hg. (23) When intermittent condensation appeared in the CO2 port as a result of expired moisture, it was easily dissipated by injecting air or [O.sub.2] through the tubing. Pulse oximetry was used to monitor arterial [O.sub.2] saturation in all 84 patients, and no patient had a level lower than 95%. The only two difficulties we encountered were one case of laryngospasm and one case of accidental extubation. These complications can occur in any patient who undergoes a laryngeal laryngeal /lar·yn·ge·al/ (lah-rin´je-al) pertaining to the larynx. la·ryn·geal or la·ryn·gal adj. Of, relating to, affecting, or near the larynx. procedure, regardless of the type of intubation intubation /in·tu·ba·tion/ (in?too-ba´shun) the insertion of a tube into a body canal or hollow organ, as into the trachea. endotracheal intubation . Both of these complications were easily remedied. In conclusion, our review confirms that the Mon-Jet tube is safe and efficient and that it satisfies the needs of both the surgeon and the anesthesiologist during microlaryngeal surgery. The most significant advantage of this system is that it allows for optimal visualization and surgical access to the larynx. The length of time required to perform each surgery and for anesthetic induction and recovery was at least comparable to that seen with standard endotracheal intubation. The Mon-Jet tube proved to be reliable for all types of microlaryngeal surgery, including [CO.sub.2] laser procedures, lesion excisions, and vocal fold injections. The lack of significant complications confirmed the safety of the Mon-Jet tube. Finally, the Mon-Jet tube was easy to use and allowed for monitoring minute ventilation and ET[CO.sub.2] levels. The Mon-Jet system has become our preferred method of delivering anesthesia during microlaryngeal surgery. References (1.) Scalco AN, Shipman ship·man n. 1. A sailor. 2. A shipmaster. WF, Tabb HG. Microscopic suspension laryngoscopy. Ann Otol Rhinol Laryngol 1960;69:1134-8. (2.) Jako GJ. Laryngoscope for microscopic observation, surgery, and photography. The development of an instrument. Arch Otolaryngol 1970;91:196-9. (3.) Kleinsasser O. Microlaryngoscopy and Endolaryngeal Microsurgery microsurgery or micromanipulation Surgical technique for operating on minute structures, with specialized, tiny precision instruments under observation through a microscope, sometimes equipped with cameras to show the operation on a monitor. . Philadelphia: W.B. Saunders, 1968. (4.) Strong MS. Microscopic laryngoscopy. A review and appraisal. Laryngoscope 1970;80:1540-52. (5.) Brooker CR, Hunsaker DH, Zimmerman AA. A new anesthetic system for microlaryngeal surgery. Otolaryngol Head Neck Surg 1998;118:55-60. (6.) Hunsaker DH. Anesthesia for microlaryngeal surgery: The case for subglottic jet ventilation. Laryngoscope 1994;104(8 Pt 2 Suppl 65):1-30. (7.) Patil V, Stehling LC, Zauder HL. A modified endotracheal tube for laser microsurgery. Anesthesiology 1979;51:571. (8.) Carden E, Crutchfield W. Anaesthesia anaesthesia anesthesia. for microsurgery of the larynx (a new method). Can Anaesth Soc J 1973;20:378-89. (9.) Benjamin B, Gronow D. A new tube for microlaryngeal surgery. Anaesth Intensive Care 1979:7:258-63. (10.) Zimmerman AA, York JK, Pickett M, HunsakerDH. Supraglottic vs subglottic jet ventilation for surgery of the larynx: The use of the Mon-Jet tube. Anestli Analg 1994;78:S502. (11.) Benumof JL, ed. Airway Management: Principles and Practice. St. Louis: Mosby, 1996:455-74. (12.) Chang JL, Bleyaert A, Bedger R. Unilateral paeumothorax following jet ventilation during general anesthesia. Anesthesiology 1980;53:244-6. (13.) Egol A, Culpepper JA, Snyder JV. Barotrauma and hypotension hypotension or low blood pressure Condition in which blood pressure is abnormally low. It may result from reduced blood volume (e.g., from heavy bleeding or plasma loss after severe burns) or increased blood-vessel capacity (e.g., in syncope). resulting from jet ventilation in critically ill patients. Chest 1985;88:98-102. (14.) Baraka AS. Tension pneumothorax complicating jet ventilation via a Cook airway exchange catheter. Anesthesiology 1999;91:557-8. (15.) Sanders RD. Two ventilating ventilating Natural or mechanically induced movement of fresh air into or through an enclosed space. The hazards of poor ventilation were not clearly understood until the early 20th century. Expired air may be laden with odors, heat, gases, or dust. attachments for bronchoscopes. Del Med J 1967;192:170-5. (16.) Lindholm CE, Ollman B, Snyder JV, et al. Cardiorespiratory car·di·o·res·pi·ra·to·ry adj. Of or relating to the heart and the respiratory system. Adj. 1. cardiorespiratory - of or pertaining to or affecting both the heart and the lungs and their functions; "cardiopulmonary effects of flexible fiberoptic bronchoscopy in critically ill patients. Chest 1978:74:362-8. (17.) Benumof JL. Airway exchange catheters: Simple concept, potentially great danger. Anesthesiology 1999;91:342-4. (18.) Gaughan SD, Benumof JL, Ozaki GT. Quantification of the jet function of a jet stylet stylet /sty·let/ (sti´lit) 1. a wire run through a catheter or cannula to render it stiff or to remove debris from its lumen. 2. a slender probe. sty·let n. 1. . Anesth Analg 1992;74:580-5. (19.) Gaughan SD, Benumof JL, Ozaki GT. Can an anesthesia machine flush valve provide for effective jet ventilation? Anesth Analg 1993;76:800-8. (20.) Woo P. Eurenius S. Dynamics of Venturi venturi a tube with a decrease in the inside diameter that is used to increase the flow velocity of the fluid and thereby cause a pressure drop; used to measure the flow velocity (a venturimeter) or to draw another fluid into the stream. jet ventilation through the operating laryngoscope. Ann Otol Rhinol Laryngol 1982;91:615-21. (21.) O'Donnell J, Williams CJ, Rosen CA, Sonbolian N. Anesthesia for an achondroplastic achondroplastic /achon·dro·plas·tic/ (-plas´tik) pertaining to, or affected with, achondroplasia. dwarf with bilateral vocal cord granuloma granuloma /gran·u·lo·ma/ (gran?u-lo´mah) pl. granulomas, granulo´mata an imprecise term for (1) any small nodular delimited aggregation of mononuclear inflammatory cells, or (2) such a collection of modified macrophages : Use of a Xomed Hunsaker Mon-Jet ventilation tube. CRNA CRNA Certified Registered Nurse Anesthetist. cRNA complementary RNA. CRNA abbr. 1998;9:67-76. (22.) Dworkin R, Benumof JL, Benumof R, Karagianes TG. The effective tracheal diameter that causes air trapping during jet ventilation. J Cardiothorac Anesth 1990;4:731-6. (23.) Streeter VL. Jet flow. In: Parker SP, ed. Fluid Mechanics Source Book. New York: McGraw-Hill, 1988:38-9. From the Division of Otolaryngology--Head and Neck Surgery. University of San Diego Medical Center (Dr. Orloff and Dr. Parhizkar), and the Division of Otolaryngology--Head and Neck Surgery, University of Campinas, Silo silo, watertight and airtight structure for making and storing silage. Silos vary in form from a covered pit, such as was used by the early Romans, to the modern storage tower, dating from the 19th cent. Paulo, Brazil (Dr. Ortiz). Reprint requests: Lisa A. Orloff, MD, Division of Otolaryngology--Head and Neck Surgery, University of California, San Diego, 200W. Arbor Dr., San Diego, CA 92103-8891. Phone: (619)543-2708; fax: (619) 543-3487; e-mail: lorloff@ucsd.edu Originally presented at the XIIth annual Pacific Voice Conference; Nov. 10, 2000; San Francisco. |
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