Laryngo-tracheal surgery presents the anaesthetist with numerous challenges including a shared airway with potential for airway compromise pre-, intra-or postoperatively. Surgical desire for a tubeless field in patients with acute or chronic laryngeal or tracheal pathology can be a daunting prospect for anaesthetists unfamiliar with these techniques. With careful preoperative planning and multidisciplinary communication, the most appropriate strategy for oxygenation and anaesthesia can be agreed. Although frequently the domain of the 'head and neck' specialist, all grades of anaesthetist may be faced with these challenging cases, particularly urgent scenarios, out of hours and in non-tertiary centres. Furthermore, proficiency in techniques such as airway topicalization, high-flow nasal oxygenation, and jet ventilation are beneficial in other areas of clinical practice. Lessons learned NAP4 The 2011 4th National Audit Project (NAP4) of the Royal College of Anaesthetists and the Difficult Airway Society investigated major complications of airway management in the United Kingdom. More than one-third of cases detailed in NAP4 involved an airway problem in association with an acute or chronic disease process in the head, neck, or trachea. 1 Approximately 70% of these patients presented with airway obstruction, with the majority requiring either anaesthesia for diagnostic and resective surgery or intervention to maintain airway patency. Expert reviewers considered airway management to have been poor in many of these reported cases, with inadequate patient assessment, planning, and team communication repeatedly cited failings. Recurring themes included airway deterioration following inhalational induction and repeated failure in direct laryngoscopy attempts. Major complications of high-pressure source ventilation A 2008 national survey exploring major complications during anaesthesia for elective laryngeal surgery in the United Kingdom found that this type of surgery was being performed in 62% of responding hospitals. 2 Across these sites, 67% were using high-pressure source ventilation (HPSV) with supraglottic, subglottic, and transtracheal routes being chosen by 86, 50, and Key points • Providing anaesthesia for surgery to the larynx and trachea is associated with a higher risk of airway complications and a need for skills in a variety of specialist techniques.

Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute 'Never Events' as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.

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Empyema of the lung is a very serious illness which must be detected quickly and treated aggressively. We report an unusual case of empyema of the lung associated with a boating accident while the patient was fishing in a sea loch off the west coast of Scotland.