Characteristics of pharyngeal paraesthesia symptoms in patients with obstructive sleep apnoea.

PURPOSE: This study aimed to investigate pharyngeal paraesthesia symptoms in patients with obstructive sleep apnoea (OSA). MATERIAL AND METHODS: Patients with snoring and suspected OSA as well as age-matched controls were recruited. All participants underwent nocturnal polysomnography (PSG) and pharyngeal paraesthesia assessment using the Glasgow-Edinburgh throat scale (GETS). The incidence and severity of pharyngeal paraesthesia symptoms were compared between the groups. RESULTS: A total of 280 patients who snored or were suspected of having OSA and 35 healthy, age-matched controls were recruited. The total pharyngeal paraesthesia symptom score was significantly higher in the OSA group than in the healthy group (12 [5, 23] vs. 3 [0, 9]; p < 0.001). The most frequent pharyngeal paraesthesia symptoms in the snore patients were Q7 (catarrh down the throat) and Q3 (discomfort/irritation in the throat), which are related to the irritability of the throat. The incidence of Q7 (OSA, 58% vs. controls, 14%; χ2 = 23.66; p < 0.001), Q3 (OSA, 46% vs. controls, 3%; χ2 = 23.07; p < 0.001), Q1 (feeling of something stuck in the throat; OSA, 33% vs. controls, 6%; χ2 = 11.00; p = 0.001), Q6 (swelling in the throat; OSA, 31% vs. controls, 0%; χ2 = 14.53; p < 0.001), Q9 (want to swallow all the time; OSA, 20% vs. controls, 6%; χ2 = 6.28; p = 0.012), Q5 (throat closing off; OSA, 24% vs. controls, 6%; χ2 = 6.16; p = 0.013), and Q2 (pain in the throat; OSA, 23% vs. controls, 6%; χ2 = 5.32; p = 0.021) was significantly higher in the OSA group than in the controls CONCLUSIONS: Patients with obstructive sleep apnoea have higher pharyngeal paraesthesia symptoms scores and tend to have irritated throats compared to healthy controls. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03506178.

A mutant MATR3 mouse model to explain multisystem proteinopathy.

Mutations in the Matrin 3 (MATR3) gene have been identified as a cause of amyotrophic lateral sclerosis (ALS) or vocal cord and pharyngeal weakness with distal myopathy (VCPDM). This study investigated the mechanism by which mutant MATR3 causes multisystem proteinopathy (MSP) including ALS and VCPDM. We first analyzed the muscle pathology of C57BL/6 mice injected with adeno-associated viruses expressing human WT or mutant (S85C) MATR3. We next generated transgenic mice that overexpress mutant (S85C) MATR3, driven by the CMV early enhancer/chicken ß-actin promoter, and evaluated their clinicopathological features. Intramuscular injection of viruses expressing WT and mutant MATR3 induced similar myogenic changes, including smaller myofibers with internal nuclei, and upregulated p62 and LC3-II. Mutant MATR3 transgenic mice showed decreased body weight and lower motor activity. Muscle histology demonstrated myopathic changes including fiber-size variation, internal nuclei and rimmed vacuoles. Spinal cord histology showed a reduced number of motor neurons, and activation of microglia and astrocytes. Comprehensive proteomic analyses of muscle demonstrated upregulation of proteins related to chaperones, stress response, protein degradation, and nuclear function. Overexpression of WT and mutant MATR3 similarly caused myotoxicity, recapitulating the clinicopathological features of MSP. These models will be helpful for analyzing MSP pathogenesis and for understanding the function of MATR3. © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Pharyngeal dysesthesias as aura in epilepsy localized to the non-dominant frontal operculum misdiagnosed as non-epileptic seizures.

The diagnosis of atypical paroxysmal events represents a significant challenge for clinicians when differentiating epileptic from nonepileptic events. The ictal manifestations of pharyngeal dysesthesias are often misdiagnosed and difficult to distinguish clinically, given their subtle features such as pharyngeal discomfort with and without autonomic symptomology. We report a rare case of isolated ictal pharyngeal dysesthesias localizing to the non-dominant frontal operculum lobe misdiagnosed as psychogenic and later confirmed by continuous video-EEG monitoring.

Quantifying the magnitude of pharyngeal obstruction during sleep using airflow shape.

RATIONALE AND OBJECTIVES: Non-invasive quantification of the severity of pharyngeal airflow obstruction would enable recognition of obstructive versus central manifestation of sleep apnoea, and identification of symptomatic individuals with severe airflow obstruction despite a low apnoea-hypopnoea index (AHI). Here we provide a novel method that uses simple airflow-versus-time ("shape") features from individual breaths on an overnight sleep study to automatically and non-invasively quantify the severity of airflow obstruction without oesophageal catheterisation. METHODS: 41 individuals with suspected/diagnosed obstructive sleep apnoea (AHI range 0-91 events·h-1) underwent overnight polysomnography with gold-standard measures of airflow (oronasal pneumotach: "flow") and ventilatory drive (calibrated intraoesophageal diaphragm electromyogram: "drive"). Obstruction severity was defined as a continuous variable (flow:drive ratio). Multivariable regression used airflow shape features (inspiratory/expiratory timing, flatness, scooping, fluttering) to estimate flow:drive ratio in 136 264 breaths (performance based on leave-one-patient-out cross-validation). Analysis was repeated using simultaneous nasal pressure recordings in a subset (n=17). RESULTS: Gold-standard obstruction severity (flow:drive ratio) varied widely across individuals independently of AHI. A multivariable model (25 features) estimated obstruction severity breath-by-breath (R2=0.58 versus gold-standard, p<0.00001; mean absolute error 22%) and the median obstruction severity across individual patients (R2=0.69, p<0.00001; error 10%). Similar performance was achieved using nasal pressure. CONCLUSIONS: The severity of pharyngeal obstruction can be quantified non-invasively using readily available airflow shape information. Our work overcomes a major hurdle necessary for the recognition and phenotyping of patients with obstructive sleep disordered breathing.

Phenotyping Pharyngeal Pathophysiology using Polysomnography in Patients with Obstructive Sleep Apnea.

RATIONALE: Therapies for obstructive sleep apnea (OSA) could be administered on the basis of a patient's own phenotypic causes ("traits") if a clinically applicable approach were available. OBJECTIVES: Here we aimed to provide a means to quantify two key contributors to OSA-pharyngeal collapsibility and compensatory muscle responsiveness-that is applicable to diagnostic polysomnography. METHODS: Based on physiological definitions, pharyngeal collapsibility determines the ventilation at normal (eupneic) ventilatory drive during sleep, and pharyngeal compensation determines the rise in ventilation accompanying a rising ventilatory drive. Thus, measuring ventilation and ventilatory drive (e.g., during spontaneous cyclic events) should reveal a patient's phenotypic traits without specialized intervention. We demonstrate this concept in patients with OSA (N = 29), using a novel automated noninvasive method to estimate ventilatory drive (polysomnographic method) and using "gold standard" ventilatory drive (intraesophageal diaphragm EMG) for comparison. Specialized physiological measurements using continuous positive airway pressure manipulation were employed for further comparison. The validity of nasal pressure as a ventilation surrogate was also tested (N = 11). MEASUREMENTS AND MAIN RESULTS: Polysomnography-derived collapsibility and compensation estimates correlated favorably with those quantified using gold standard ventilatory drive (R = 0.83, P < 0.0001; and R = 0.76, P < 0.0001; respectively) and using continuous positive airway pressure manipulation (R = 0.67, P < 0.0001; and R = 0.64, P < 0.001; respectively). Polysomnographic estimates effectively stratified patients into high versus low subgroups (accuracy, 69-86% vs. ventilatory drive measures; P < 0.05). Traits were near-identical using nasal pressure versus pneumotach (N = 11, R ≥ 0.98, both traits; P < 0.001). CONCLUSIONS: Phenotypes of pharyngeal dysfunction in OSA are evident from spontaneous changes in ventilation and ventilatory drive during sleep, enabling noninvasive phenotyping in the clinic. Our approach may facilitate precision therapeutic interventions for OSA.

Longitudinal Kinematic Evaluation of Pharyngeal Swallowing Impairment in Thyroidectomy Patients.

The aim of this study was to assess pharyngeal swallowing impairments in thyroidectomy patients and to delineate the contributory kinematic components. Forty consecutive patients (mean age = 47.33 years) and fourteen age- and sex-matched heathy adult volunteers (mean age = 42.64 years) participated in this study. A videofluoroscopic swallowing study (VFSS) was performed 1 day prior to surgery, and at 1 week and 3 months post-surgery. VFSS images were evaluated using the Modified Barium Swallowing Impairment Profile (MBSImp). Kinematic and temporal aspects of swallowing were characterized by measurement of maximum hyoid and laryngeal excursion, pharyngeal transit duration, laryngeal response duration (LRD), and laryngeal closure duration at each three time-points. At 1 week post-surgery, only pharyngeal impairment was significantly deteriorated than pre-surgery (p = 0.001). However, at 3 months, a significant improvement was observed to pre-surgery level (p = 0.01). Post-surgery, maximum hyoid excursion was significantly reduced in patients compared controls (p = 0.001). Although the maximal distance of the hyoid and the laryngeal excursion was shorter than before surgery, laryngeal excursion at all three time-points was similar to that of controls. At all three time-points, LRD was significantly longer in patients than in controls (p = 0.01). Following thyroidectomy, pharyngeal aspects of swallowing as measured by the MBSImp and kinematic aspects of swallowing were reduced with incomplete recovery at 3 months. These exploratory data may guide decision regarding management of pharyngeal swallowing impairment with patients undergoing total thyroidectomy.

High-resolution manometry in patients with and without globus pharyngeus and/or symptoms of laryngopharyngeal reflux.

BACKGROUND: Globus pharyngeus is common and has a low cure rate. Its etiology is complex and reported to be associated with laryngopharyngeal reflux (LPR). However, some patients with globus do not exhibit any reflux symptoms or respond to proton pump inhibitors (PPIs) treatments. The purpose of this study was to clarify the related risk factors of these patients with a final objective of improving the curative effect. METHODS: Forty two patients afflicted with globus pharyngeus (G group) and 38 patients without globus pharyngeus (NG group) were included in this study. According to the laryngopharyngeal Reflux Symptom Index and the response to PPIs treatments, the patients were further divided into reflux groups (G-R, NG-R) and non-reflux groups (G-NR, NG-NR). High Resolution Manometry (HRM) was performed to assess esophageal motility. Questionnaires, including categories such as life exposure factors, were conducted. RESULTS: a) The average resting and residual pressures of the upper esophageal sphincter (UES) in the G-NR group was higher than in the NG-NR and NG-R groups (P < 0.05). b) The average resting and residual pressures of the lower esophageal sphincter showed no differences between the G-NR group and the NG-NR group (P > 0.05). c) The esophageal distal contractile integral score of the G-NR group was not different from the NG-NR group (P > 0.05). d) Compared to the NG-NR group, the G-NR group showed higher incidence of stress, smoking, drinking, high salt and anxiety (P < 0.05). CONCLUSIONS: Globus pharyngeus without LPR may occur due to high UES pressure. Stress, smoking, alcoholic drinking, high salt and anxiety may be its risk factors.

Oropharyngeal lesions in pityriasis rosea.

BACKGROUND: Pityriasis rosea (PR) is an exanthematous disease associated with the endogenous systemic reactivation of human herpesvirus-6 (HHV-6) and human herpesvirus-7 (HHV-7). Oropharyngeal lesions may be associated with the exanthema, but anecdotal evidence suggests that few dermatologists are aware of their occurrence. OBJECTIVE: Classifying oropharyngeal lesions in PR, establishing their prevalence, and assessing their possible association with different PR forms. METHODS: The records of all PR cases diagnosed in the Dermatology Clinic of Genoa University between 2003 and 2016 were retrospectively reviewed to examine sex and age of the patients, PR type, presence of enanthema, systemic symptoms, specific anti-HHV-6 and or HHV-7 serology, and HHV-6 and/or HHV-7 DNA loads. RESULTS: The oropharyngeal mucosa was carefully examined in 527 patients with PR. Painless oropharyngeal lesions were observed in 149 patients with PR (28%) and classified as erythematomacular, macular and papular, erythematovesicular, and petechial lesions. The petechial and macular and papular patterns were those most frequently observed. There was no statistically significant difference in the levels of HHV-6 and HHV-7 viremia in the plasma of patients with enanthema and those without. LIMITATIONS: Because this was a retrospective study, biopsies on mucosal lesions were not performed. CONCLUSION: Our findings showed that enanthemas are frequently associated with forms of PR different from the classic form.

Airway and circulatory collapse due to retropharyngeal hematoma after blunt vertebral artery injury.

Retropharyngeal hematoma following blunt cervical spine injury is a known cause of airway obstruction, but it is not known to cause hemorrhagic shock. We report the case of a massive retropharyngeal hematoma caused by a blunt vertebral artery transection leading simultaneously to airway obstruction and hemorrhagic shock. An 83-year-old woman was injured in a motorcycle accident. In the field, the patient exhibited paradoxical breathing with no breath sounds, and her blood pressure could not be measured. Therefore, emergency intubation and fluid resuscitation were initiated and the patient was transferred to the emergency department. Computed tomography angiography revealed a massive retropharyngeal hematoma with contrast extravasation from the right vertebral artery, which caused airway obstruction and hemorrhagic shock. The right vertebral artery was transected at the C5 level, which was associated with C4/C5 dislocation. Vertebral artery transection was successfully treated by endovascular embolization, which was followed by complication of asymptomatic posterior circulation stroke. Blunt vertebral artery transection can cause massive retropharyngeal hematoma, which can rapidly expand and lead to hemorrhagic shock in addition to airway obstruction. In cases of massive retropharyngeal hematoma with hemorrhagic shock following blunt cervical spine injury, blunt vertebral artery transection should be suspected. If blunt vertebral artery transection is detected and hemorrhagic shock is persistent, endovascular embolization should be performed immediately in addition to emergency intubation.

How we do it: the intra-operative identification of a pharyngocele.

A pharyngocele is an uncommon condition, where pharyngeal mucosa herniates through the thyrohyoid membrane. It can be difficult to locate when the patient is at rest. To locate the pharyngocele intra-operatively, a bag valve mask was used to inflate the herniated mucosa. We describe a cost-effective and simple way to locate the pharyngocele intra-operatively.

Reliability of a laryngo-pharyngeal esthesiometer and a method for measuring laryngo-pharyngeal mechano-sensitivity in a prospectively recruited cohort of patients.

BACKGROUND: There are not reliable methods for measuring laryngo-pharyngeal mechano-sensitivity (LPMS). We aimed to determine the reliability of a new method for measuring LPMS using a new laryngo-pharyngeal esthesiometer (LPEER) in a prospective cohort of dysphagic stroke and non-dysphagic patients. The patients underwent clinical and endoscopic evaluations of swallowing (FESSST). The LPMS assessments consisted of measurements by an expert and a novel rater of the laryngeal-adductor reflex threshold (LART), cough reflex threshold (CRT) and gag reflex threshold (GRT) using the LPEER. We assessed the Bland-Altman limits of agreement, the intraclass correlation coefficients (ICCs) and Spearman correlation coefficients (SCCs). For the inter-rater comparisons, we contrasted the expert and novel raters. A total of 1608 measurements were obtained from 34 dysphagic stroke patients and 33 non-dysphagic patients. The intra-rater ICCs for all reflex thresholds were >0.90. The inter-rater ICCs were 0.87 for the LART, 0.79 for the CRT and 0.70 for the GRT. The intra-rater SCCs for all reflex thresholds were above 0.88 (P < 0.0001). The inter-rater SCC were 0.80 for the LART, 0.79 for the CRT and 0.70 for the GRT (all P < 0.0001). The Bland-Altman plots revealed good agreement for the LART and CRT and moderate agreement for the GRT. The median normal value was 0.14 mN for the LART, 4.4 mN for the CRT and 11.9 mN for the GRT. The median thresholds values in patients with aspiration were LART: 1.31 mN; CRT: 32.9 mN and GRT: 32.9 mN (all P < 0.006 vs normal thresholds). The LPEER exhibited substantial to excellent intra- and inter-rater reliability.

Clinical Characteristics of Dysphagia in Children with Down Syndrome.

Aspiration is an often unrecognized comorbidity in children with Down syndrome with serious medical consequences. This retrospective chart review of swallow study reports characterizes oral and pharyngeal phase dysphagia and diet modifications on videofluoroscopic swallow studies (VFSS) in a large cohort of children with Down syndrome. A total of 158 pediatric patients (male = 95; female = 63; mean age 2.10 years, SD 3.17 years) received an initial VFSS at a pediatric teaching hospital as part of their medical care. A total of 56.3 % (n = 89) children had pharyngeal phase dysphagia with aspiration and deep laryngeal penetration occurring most frequently. Of the 61 patients who aspirated, 90.2 % (n = 55) did so silently with no cough or overt clinical symptoms. In 76.7 % of cases of pharyngeal phase dysphagia, a functional feeding plan, with use of thickened liquids or change in feeding system to control flow rate and/or bolus size, was able to be established, which allowed children to continue eating by mouth. Thickened liquids (76.7 %, n = 46) were the most effective adaptation, with change in feeding system alone effective in only 8.3 % (n = 5) cases. Oral phase dysphagia was reported in the majority of patients (63.8 %, n = 88/138); however, this was not predictive of pharyngeal phase dysphagia. Age, sex, and reason for referral, including prior clinical symptoms, did not have a statistically significant impact on the presence of dysphagia. This comprehensive review has application to clinical understanding and management of dysphagia in children with Down syndrome.

Pharyngeal spasticity due to dantrolene.

WHAT IS KNOWN AND OBJECTIVE: Dantrolene can be combined with baclofen to better treat spasticity, but may cause muscular weakness and dysphagia. We instead describe a pharyngeal spasm due to dantrolene. CASE SUMMARY: A 12-year-old male received dantrolene 3 mg/kg/day in adjunct to baclofen 2 mg/kg/day, to improve spasticity. After 5 days of full-dose dantrolene, his dysphagia worsened and he developed pharyngeal spasm. Dantrolene was suspected for an adverse reaction and removed. The patient subsequently improved. WHAT IS NEW AND CONCLUSION: Causality analysis determined a probable relationship between dantrolene and pharyngeal spasm. This may be due to direct muscle contraction by dantrolene, an effect seen previously in vitro.

Otolaryngologic manifestations of diffuse idiopathic skeletal hyperostosis.

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by formation of large cervical osteophytes that may compress the posterior wall of the aerodigestive tract. It is a rare cause of dysphagia in the elderly. The aim of this study was to investigate the various otolaryngologic manifestations of DISH. Eleven elderly patients with DISH were included in the study. All patients presented with dysphagia that was graded on the swallowing screening tool (EAT-10), and the diagnosis of DISH was based on computed tomographic criteria. The patients were subjected to otolaryngologic examination and flexible laryngoscopy. Polysomnography was used for patients with excessive daytime sleepiness for detection of obstructive sleep apnea (OSA). In addition to dysphagia of varying severity, OSA was found in nine patients, change of voice in six, globus sensation in seven, aspiration in three, and cervical pain in seven. Flexible laryngoscopy showed bulging of the posterior pharyngeal wall in all patients. DISH may be an unrecognized contributory factor to both dysphagia and OSA in the elderly. Change of voice, aspiration, globus sensation, and cervical pain are other otolaryngologic manifestations that may be encountered symptoms of the disease. An otolaryngologist should be aware of the disease that may be overlooked, and computed tomography is a confirmatory diagnostic method.

Serine/threonine phosphatase (SP-STP), secreted from Streptococcus pyogenes, is a pro-apoptotic protein.

This investigation illustrates an important property of eukaryote-type serine/threonine phosphatase (SP-STP) of group A Streptococcus (GAS) in causing programmed cell death of human pharyngeal cells. The secretory nature of SP-STP, its elevated expression in the intracellular GAS, and the ability of wild-type GAS but not the GAS mutant devoid of SP-STP to cause apoptosis of the host cell both in vitro and in vivo suggest that GAS deploys SP-STP as an important virulence determinant to exploit host cell machinery for its own advantage during infection. The exogenously added SP-STP is able to enter the cytoplasm and subsequently traverses into the nucleus in a temporal fashion to cause apoptosis of the pharyngeal cells. The programmed cell death induced by SP-STP, which requires active transcription and de novo protein synthesis, is also caspase-dependent. Furthermore, the entry of SP-STP into the cytoplasm is dependent on its secondary structure as the catalytically inactive SP-STP with an altered structure is unable to internalize and cause apoptosis. The ectopically expressed wild-type SP-STP was found to be in the nucleus and conferred apoptosis of Detroit 562 pharyngeal cells. However, the catalytically inactive SP-STP was unable to cause apoptosis even when intracellularly expressed. The ability of SP-STP to activate pro-apoptotic signaling cascades both in the cytoplasm and in the nucleus resulted in mitochondrial dysfunctioning and perturbation in the phosphorylation status of histones in the nucleus. SP-STP thus not only functions as a virulence regulator but also as an important factor responsible for host-related pathogenesis.

Muscle weakness predicts pharyngeal dysfunction and symptomatic aspiration in long-term ventilated patients.

BACKGROUND: Prolonged mechanical ventilation is associated with muscle weakness, pharyngeal dysfunction, and symptomatic aspiration. The authors hypothesized that muscle strength measurements can be used to predict pharyngeal dysfunction (endoscopic evaluation-primary hypothesis), as well as symptomatic aspiration occurring during a 3-month follow-up period. METHODS: Thirty long-term ventilated patients admitted in two intensive care units at Massachusetts General Hospital were included. The authors conducted a fiberoptic endoscopic evaluation of swallowing and measured muscle strength using medical research council score within 24 h of each fiberoptic endoscopic evaluation of swallowing. A medical research council score less than 48 was considered clinically meaningful muscle weakness. A retrospective chart review was conducted to identify symptomatic aspiration events. RESULTS: Muscle weakness predicted pharyngeal dysfunction, defined as either valleculae and pyriform sinus residue scale of more than 1, or penetration aspiration scale of more than 1. Area under the curve of the receiver-operating curves for muscle strength (medical research council score) to predict pharyngeal, valleculae, and pyriform sinus residue scale of more than 1, penetration aspiration scale of more than 1, and symptomatic aspiration were 0.77 (95% CI, 0.63-0.97; P = 0.012), 0.79 (95% CI, 0.56-1; P = 0.02), and 0.74 (95% CI, 0.56-0.93; P = 0.02), respectively. Seventy percent of patients with muscle weakness showed symptomatic aspiration events. Muscle weakness was associated with an almost 10-fold increase in the symptomatic aspiration risk (odds ratio = 9.8; 95% CI, 1.6-60; P = 0.009). CONCLUSION: In critically ill patients, muscle weakness is an independent predictor of pharyngeal dysfunction and symptomatic aspiration. Manual muscle strength testing may help identify patients at risk of symptomatic aspiration.

Head-to-head comparison of single-breath and tidal-breath exhaled nitric oxide measurements.

BACKGROUND: Exhaled nitric oxide (eNO) is an endogenous gas involved in airway pathophysiology and is determined in orally exhaled air by various techniques. However, traditional single-breath technique (eNO(SB)) requires active cooperation and is not always easily practicable (especially in young children); simpler techniques including tidal breathing measurements (eNO(TB)) are not standardized. The aim of this study was to evaluate the possible correlation and correspondence between eNO(SB) and eNO(TB) and the impact of potential confounders in children with chronic adenotonsillar disease. METHODS: Eighty-six children (mean age 8.7 ± 3.2 y) underwent eNO assessment by means of eNO(SB) and eNO(TB). The correlation among eNO(TB), eNO(SB), and other potential confounders (i.e., gender, age, weight, height, BMI, and passive smoking exposure) were studied. RESULTS: The analyses showed a poor correspondence between eNO(SB) and eNO(TB), with the latter underestimating (P < 0.001) mean eNO values: 6.4 parts per billion (ppb) (95% confidence interval (CI): 8.4-11.4 ppb) vs. 9.8 ppb (95% CI: 5.6-7.3 ppb). A greater correlation was found between eNO(SB) and eNO(TB) in children younger than 6 y. Only eNO(SB) and age predicted eNO(TB) (R2 = 43.6%). CONCLUSION: eNO(TB) is not a good predictor of eNO(SB) in children. Constant-flow eNO(SB) is the technique of choice for eNO assessment in young children.

Laryngeal sensory dysfunction in laryngeal hypersensitivity syndrome.

BACKGROUND AND OBJECTIVE: Diseases associated with laryngeal dysfunction include chronic refractory cough (CRC), paradoxical vocal fold movement (PVFM), muscle tension dysphonia (MTD) and globus pharyngeus. We hypothesized the presence of a common sensory laryngeal dysfunction, the 'laryngeal hypersensitivity' syndrome, in these conditions. The aim of the study was to compare symptoms and sensory function in patients with CRC, PVFM, MTD and globus. METHODS: The 103 participants included healthy controls (n = 13) and four case groups: CRC (n = 33), PVFM (n = 28), globus pharyngeus (n = 11) and MTD (n = 18). Participants completed self-report questionnaires: Symptom Frequency and Severity Scale, Voice Handicap Index and the Laryngeal Paraesthesia Questionnaire; and quantitative sensory testing: capsaicin cough reflex sensitivity, hypertonic saline challenge, the timed swallow test, acoustic voice testing, cough frequency monitor and a voice stress test. RESULTS: All case groups reported a high-symptom burden in comparison to controls. The case groups showed a similar pattern of symptoms, with impairment in each of the cough, respiration, vocal and upper airway symptom domains. Objective testing revealed significant sensory impairment in the case groups compared to controls and also showed an overlap in sensory dysfunction between the four case groups. Furthermore, there was cross-sensory stimulation of symptoms whereby stimulation of a particular response resulted in symptoms in another domain. CONCLUSIONS: These discrete clinical laryngeal syndromes display considerable overlap in their clinical features and a common sensory dysfunction, supporting the 'laryngeal hypersensitivity' hypothesis. Reconceptualizing functional laryngeal disorders as a form of laryngeal hypersensitivity syndrome provides an alternative approach to management of these perplexing conditions.

Exhaled nitric oxide levels in children with chronic adenotonsillar disease.

Exhaled nitric oxide (eNO) is a highly reactive biological mediator that has recently been associated with chronic tonsillar disease in adults, but there are no published data concerning eNO levels in their pediatric counterparts. The aim of this study is to measure mean eNO levels in children with chronic adenotonsillitis or adenotonsillar hypertrophy, and assess the effects of potential confounding factors. Children aged 3-17 years were divided into three groups (chronic adenotonsillitis, adenotonsillar hypertrophy and controls). Their eNO levels were measured in accordance with the international guidelines, and their other clinical and anamnestic characteristics were recorded. The mean eNO level in the children with chronic adenotonsillitis was slightly higher than that in the other groups, but there was no statistically significant between-group difference. Age (p=0.009), allergy (p=0.05) and body mass index (p=0.03), but not the mean grade of adenoidal or tonsil hypertrophy, were all statistically related to mean eNO levels. These preliminary results indicate the lack of an increase in mean eNO levels in children with chronic adenotonsillar disease, with no substantial difference between children with chronic adenotonsillitis and those with adenotonsillar hypertrophy.