Exercise induced laryngeal obstruction (EILO) in children and young people: Approaches to assessment and management.

Exercise Induced Laryngeal Obstruction (EILO) is characterised by breathlessness, cough and/or noisy breathing particularly during high intensity exercise. EILO is a subcategory of inducible laryngeal obstruction where exercise is the trigger that provokes inappropriate transient glottic or supraglottic narrowing. It is a common condition affecting 5.7-7.5% of the general population and is a key differential diagnosis for young athletes presenting with exercise related dyspnoea where prevalence rates go as high as 34%. Although the condition has been recognised for a long time, little attention, and awareness of the condition results in many young people dropping out of sporting participation due to troublesome symptoms. With evolving understanding of the condition, diagnostic tests and interventions, this review looks to present the current available evidence and best practice when managing young people with EILO.

The continuous laryngoscopy exercise test in severe or in difficult-to-treat asthma in adults: a systematic review.

OBJECTIVE: A systematic review was performed to determine if the continuous laryngoscopy exercise test (CLE) has been used in the diagnostics of exercise dyspnea in adults with asthma, and whether inducible laryngeal obstruction (ILO) is found in those with asthma or with severe or difficult-to-treat asthma. DATA SOURCES: We used Scopus and PubMed databases. The articles published up to 13 August 2019 were considered. STUDY SELECTIONS: We excluded manuscripts that did not contain information about adult patients with asthma. We included six studies from 59 search results in Scopus and none from the 17 search results in PubMed. RESULTS: The articles included 455 study individuals. Of these, 229 (50.3%) had diagnosed asthma or were treated with asthma medication. Altogether 31/229 (13.5%) subjects with diagnosis of asthma or previous asthma treatment had exercise-induced laryngeal obstruction (EILO) as comorbidity. The CLE test was performed on 229 patients with asthma. The method was used only for differential diagnosis of exercise-induced dyspnea to confirm EILO. At least 10/455 (2.2%) out of the 455 subjects experienced adverse events. CONCLUSIONS: This systematic review revealed that only a small proportion of patients with asthma had undergone the CLE test to assess exercise-induced dyspnea. None of the selected manuscripts reported severity of asthma. Whether CLE provides a valuable diagnostic tool for patients with severe or difficult-to-treat asthma cannot be determined according to this review.

Development and validation of the Exercise-Induced Laryngeal Obstruction Dyspnea Index (EILODI).

BACKGROUND: Exercise-induced laryngeal obstruction (EILO) causes exertional dyspnea and is important for its effect on quality of life, diagnostic confusion with exercise-induced asthma, and health care resource utilization. There is no validated patient-reported outcome measure specific to EILO. OBJECTIVE: We sought to develop, validate, and define a minimal clinically important difference for a patient-reported outcome measure to be used with adolescents and young adults with EILO. METHODS: A multidisciplinary group created a preliminary measure, modified by a 10-member participant focus group, with 20 items scored along a 5-point Likert scale. A subsequent cohort of participants recruited from a clinic, aged 12 to 21 years, with confirmed EILO by continuous laryngoscopy during exercise testing (1) completed the measure at 3 points in time over 28 days and (2) provided anchoring data in the form of a daily exercise log and categorical self-assessments of clinical improvement. Thirty additional participants without exertional dyspnea served as controls. RESULTS: Two hundred nineteen subjects with mild to severe EILO participated in the exploratory factor analysis, which identified 7 factors within the preliminary outcome measure. After a process of item reduction, a 12-item metric with a total score ranging from 0 to 48 was developed. Mean scores of patients with EILO and healthy controls at baseline were 28.8 ± 7.4 and 4.5 ± 7.4, respectively. A minimal clinically important difference of 6 was determined by comparison of index change with changes in categorical self-assessments of improvement. CONCLUSIONS: This is the first patient-reported outcome measure specifically designed for adolescents and young adults with EILO.

Conundrums in the breathless athlete; exercise-induced laryngeal obstruction or asthma?

PURPOSE: Exercise-induced bronchoconstriction (EIB) and exercise-induced laryngeal obstruction (EILO) are the two disorders commonly considered when athletes complain of exertional dyspnea. They are highly different but often confused. We aimed to address this diagnostic challenge and its consequences in elite athletes. METHODS: We included all athletes competing at national or international level, referred to our institution for workup for EILO during 2013-2016. We diagnosed EILO from video-recorded laryngoscopy performed during maximal cardiopulmonary treadmill exercise (CLE test). Symptoms and previous diagnostic evaluations were obtained from referral letters and chart reviews. RESULTS: Exercise-induced laryngeal obstruction was diagnosed in 73/101 referred athletes, of whom 70/73 had moderate/severe supraglottic obstruction and 3/73 had primarily glottic obstruction with only minor supraglottic involvement. Of the 73 athletes with EILO, we were able to identify objective tests for asthma in 55 participants, of whom 22 had findings supporting asthma. However, 58/73 had used asthma therapy at some time previously, with current use in 28. Only three reported that asthma medication had improved their exercise-related breathing problems, two of whom with tests confirming asthma. Treatment for EILO improved breathing problems in all but four. CONCLUSIONS: Objective testing verified EILO in most of the referred athletes. EILO coexisting with asthma was common, and large proportions had used asthma medication; however, few reported effect on exercise-related breathing problems. Unexplained persistent exertional dyspnea must not lead to indiscriminate escalation of asthma treatment, but instead incite investigation for EILO, either as a co-morbidity or as a differential diagnosis.

The role of cardiopulmonary exercise testing in evaluating children with exercise induced dyspnoea.

Exercise induced dyspnoea (EID) is a common manifestation in children and adolescents. Although EID is commonly attributed to exercise induced bronchoconstriction, several conditions other than asthma can cause EID in otherwise healthy children and adolescents. Cardiopulmonary exercise testing (CPET) offers a non-invasive comprehensive assessment of the cardiovascular, ventilatory and metabolic responses to exercise and is a powerful diagnostic and prognostic tool. CPET is a reproducible, non-invasive form of testing that allows for comparison against age- and gender-specific norms. CPET can assess the child's exercise capacity, determine the limiting factors associated with this, and be used to prescribe individualised interventions. EID can occur due to asthma, exercise induced laryngeal obstruction, breathing pattern disorders, chest wall restriction and cardiovascular pathology among other causes. Differentiating between these varied causes is important if effective therapy is to be initiated and quality of life improved in subjects with EID.

Exercise inducible laryngeal obstruction: diagnostics and management.

Obstruction of the central airways is an important cause of exercise-induced inspiratory symptoms (EIIS) in young and otherwise healthy individuals. This is a large, heterogeneous and vastly understudied group of patients. The symptoms are too often confused with those of asthma. Laryngoscopy performed as symptoms evolve during increasing exercise is pivotal, since the larynx plays an important role in symptomatology for the majority. Abnormalities vary between patients, and laryngoscopic findings are important for correct treatment and handling. The simplistic view that all EIIS is due to vocal cord dysfunction [VCD] still hampers science and patient management. Causal mechanisms are poorly understood. Most treatment options are based on weak evidence, but most patients seem to benefit from individualised information and guidance. The place of surgery has not been settled, but supraglottoplasty may cure well-defined severe cases. A systematic clinical approach, more and better research and randomised controlled treatment trials are of utmost importance in this field of respiratory medicine.

Exercise induced laryngeal obstruction: a review of diagnosis and management.

Exercise induced laryngeal obstruction (EILO) is a condition where inappropriate vocal cord or glottic closure occurs during exercise. This review of the literature provides an overview of the current understanding of the definition, epidemiology, diagnosis and management of EILO. Using The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines the Cochrane, Embase, Ovid MEDLINE and PubMed databases were searched. Four search domains "exercise", "induced", "laryngeal" and "obstruction" were used. Primary searching found 469 records, 308 were excluded following screening of titles and citation. 100 were duplicates, a further 47 studies were excluded after applying inclusion and exclusion criteria. Two studies were identified following cross-referencing. A total of 15 studies were included. The last search date was 6/06/15. Average prevalence in the general adolescent population and athletes was 7.1 and 35.2 %, respectively. Dyspnoea was reported in 96.5, 99 and 100 % of three EILO patient cohorts. Two studies (n = 107) reported continuous laryngoscopy during exercise (CLE) testing could differentiate between patients and controls. In two studies (n = 33) the visual analogue scale (VAS) showed a beneficial effect of endoscopic supraglottoplasty (ES). Thirty-eight out of 43 patients who received two or more laryngeal control therapy sessions (LCT) had improvement or resolution of EILO symptoms. Exercise induced dyspnoea is the most common EILO symptom. EILO has a high occurrence in adolescents and athletes. The CLE test is the current gold standard for EILO diagnostics. Management of EILO includes both surgical and non-surgical interventions.

Comparison between two assessment methods for exercise-induced laryngeal obstructions.

Exercise-induced laryngeal obstructions (E-ILOs) are important differential diagnoses to exercise-induced asthma and are diagnosed by the continuous laryngoscopy exercise (CLE) test. There are two different methods for evaluating the severity of E-ILOs using recordings from the CLE test; the CLE score and EILOMEA. The aim of this study was to investigate the consistency between these methods. Using their respective method, the developers of each method evaluated 60 laryngoscopic recordings from patients with different subtypes and various levels of severity of E-ILOs. The CLE score evaluates glottic and supraglottic obstructions on a 4-grade scale. EILOMEA uses software to calculate the obstruction severity on continuous scales from a still frame of the larynx during maximal obstruction giving three parameters reflecting glottic and supraglottic obstruction. The means of the EILOMEA measures differed significantly for CLE score 1 vs. 2 and 2 vs. 3, but not for 0 vs. 1 for glottic as well as supraglottic obstructions. The EILOMEA method does not distinguish between CLE score 0 and 1, but otherwise the methods correlate. Since previous studies have suggested that only CLE scores of 2 and 3 reflect a severity of E-ILOs of clinical importance, this lack of the EILOMEA method is not crucial for a correct medical evaluation.

A speech therapy treatment protocol for exercise induced laryngeal obstruction.

Background: Exercise induced laryngeal obstruction (EILO) is a common cause of exertional breathing problems in young individuals, relevant to 5%-7% of young people. It is caused by paradoxical inspiratory adduction of laryngeal structures and diagnosed by continuous visualization of the larynx during high intensity exercise. Empirical data suggest that EILO consists of different subtypes that require different therapeutic approaches. Currently applied treatment approaches do not rest on randomized controlled trials (RCTs), and thus evidence-based guidelines cannot be established. This protocol describes the speech therapy treatment approach which is applied to EILO patients in a large prospective RCT called HelpILO. Methods and analysis: Consenting patients consecutively diagnosed with EILO at Haukeland University Hospital are randomized into four treatment arms. Speech therapy is represented in two of these, provided in a structured manner based on general speech therapy principles and abdominal breathing, combined with experience obtained with these patients at our hospital during the last decades. The main outcome measure of HelpILO is changes of laryngoscopically visualized laryngeal adduction, rated at peak exercise before vs. after interventions, using a validated scoring system. Ethics and dissemination: Despite widespread use of speech therapy in patients with EILO, this approach is insufficiently tested in RCTs, and the study is therefore considered ethically appropriate. The study will provide knowledge listed as a priority in a recent statement issued by major respiratory and laryngological societies and requested by clinicians and researchers engaged in this area. The results will be presented at relevant conferences, patient fora, and media platforms, and published in relevant peer reviewed international journals.

Epiglottic retraction is useful in diagnosis of exercise-induced laryngeal obstruction.

BACKGROUND: Exercise-induced laryngeal obstruction (EILO) is distinguished as upper airway obstruction accompanied by inspiratory dyspnoea and stridor during highly intensive exercises. Epiglottic retraction in the diagnosis of EILO has not been sufficiently explored. AIMS/OBJECTIVES: We highlight the importance of epiglottic retraction in patients with EILO by evaluation by several diagnostic methods for EILO. Consideration of epiglottic retraction may be important for accurate diagnosis of EILO. RESULTS: Epiglottic retraction could be observed in three patients by laryngoscopy during heavy breathing and in two patients by continuous laryngoscopy during exercise. Stridor occurred by the forward prolapse of the arytenoids, but not by epiglottic retraction. In comparison with three athletes from other sports, lung volume was significantly greater in four swimmers although it was not different related to depending on the existence of epiglottic retraction. CONCLUSIONS AND SIGNIFICANCE: Laryngoscopy during heavy breathing is suggested to be useful to detect the epiglottic retraction, which might be overlooked if only continuous laryngoscopy during exercise is used. Epiglottic retraction was not rare in Japanese swimmers' exercise-induced laryngeal obstruction in our cohort and it might be related to the greater lung volume.

Application of computational fluid dynamics to investigate pathophysiological mechanisms in exercise-induced laryngeal obstruction.

The underlying pathophysiological mechanisms of exercise-induced laryngeal obstruction (EILO) remain to be fully established. It is hypothesized that high inspiratory flow rates can exert a force on laryngeal airway walls that contribute to its inward collapse causing obstruction. Computational fluid dynamics (CFD) presents an opportunity to explore the distribution of forces in a patient-specific upper airway geometry. The current study combined exercise physiological data and CFD simulation to explore differences in airflow and force distribution between a patient with EILO and a healthy matched control. Participants underwent incremental exercise testing with continuous recording of respiratory airflow and laryngoscopic video, followed by an MRI scan. The respiratory and MRI data were used to generate a subject-specific CFD model of upper respiratory airflow. In patient with EILO, the posterior supraglottis experiences an inwardly directed net force, whose magnitude increases nonlinearly with larger flow rates, with slight changes in the direction toward the center of the airway. The control demonstrated an outwardly directed force at all regions of the wall, with a magnitude that increases linearly with larger flow rates. A comparison is made between the CFD results and endoscopic visualization of supraglottic collapse, and a very good agreement is found. The current study presents the first hybrid physiological and computational approach to investigate the pathophysiological mechanisms of EILO, with preliminary findings showing great potential, but should be used in larger sample sizes to confirm findings.NEW & NOTEWORTHY The current study is the first to use a hybrid combined computational fluid dynamics (CFD) and exercise physiology approach to investigate pathophysiology in exercise-induced laryngeal obstruction (EILO). The hybrid methodology is a promising approach to explore the pathophysiological mechanisms underlying the condition. Notable differences occur in the distribution of airflow and wall forces between the EILO and control participants, which align with symptoms and visual observations.

Exercise-Induced Bronchoconstriction in Children: State of the Art from Diagnosis to Treatment.

Exercise-induced bronchoconstriction (EIB) is a common clinical entity in people with asthma. EIB is characterized by postexercise airway obstruction that results in symptoms such as coughing, dyspnea, wheezing, chest tightness, and increased fatigue. The underlying mechanism of EIB is not completely understood. "Osmotic theory" and "thermal or vascular theory" have been proposed. Initial assessment must include a specific work-up to exclude alternative diagnoses like exercise-induced laryngeal obstruction (EILO), cardiac disease, or physical deconditioning. Detailed medical history and clinical examination must be followed by basal spirometry and exercise challenge test. The standardized treadmill running (TR) test, a controlled and standardized method to assess bronchial response to exercise, is the most adopted exercise challenge test for children aged at least 8 years. In the TR test, the goal is to reach the target heart rate in a short period and maintain it for at least 6 min. The test is then followed by spirometry at specific time points (5, 10, 15, and 30 min after exercise). In addition, bronchoprovocation tests like dry air hyperpnea (exercise and eucapnic voluntary hyperpnea) or osmotic aerosols (inhaled mannitol) can be considered when the diagnosis is uncertain. Treatment options include both pharmacological and behavioral approaches. Considering medications, the use of short-acting beta-agonists (SABA) just before exercise is the commonest option strategy, but daily inhaled corticosteroids (ICS) can also be considered, especially when EIB is not controlled with SABA only or when the patients practice physical activity very often. Among the behavioral approaches, warm-up before exercise, breathing through the nose or face mask, and avoiding polluted environments are all recommended strategies to reduce EIB risk. This review summarizes the latest evidence published over the last 10 years on the pathogenesis, diagnosis using spirometry and indirect bronchoprovocation tests, and treatment strategies, including SABA and ICS, of EIB. A specific focus has been placed on EIB management in young athletes, since this condition can not only prevent them from practicing regular physical activity but also competitive sports.

A multidimensional strategy to managing dysfunctional breathing and exercise-induced laryngeal obstruction in adolescent athletes.

BACKGROUND: Exercise induced laryngeal obstruction (EILO) causes inspiratory distress in the upper airway in many adolescent athletes. The nature of EILO is not fully understood, and effective management strategies are lacking. This study aimed to assess the effectiveness of a multidimensional individually tailored intervention, including Norwegian Psychomotor Physiotherapy (NPMP), elements of cognitive behavioural therapy and a rehabilitation plan, in reducing inspiratory distress and dysfunctional breathing in adolescent athletes with EILO. METHODS: A mixed methods design, which combined qualitative and quantitative research, was used. Data, including subjective experiences of respiratory distress, findings from body examinations and objective measurements of lung function and aerobic capacity were gathered before and after a five month intervention involving 18 participants. RESULTS: Following the intervention, the participants showed a reduction in respiratory distress and anxiousness associated with their breathing difficulties. Furthermore, the participants reported to be more in control of their breathing. The body assessments revealed a more functional breathing motion and improved posture, which imply that the breathing was less thoracic and more diaphragmatic in rest and exercise in all participants after the intervention. CONCLUSIONS: Our results suggest that a multidimensional individually tailored intervention, including NPMP based physiotherapy, cognitive behavioural therapy elements, and a rehabilitation plan may reduce inspiratory distress and dysfunctional breathing in athletes with EILO. TRIAL REGISTRATION: ClinicalTrials.gov Protocol Registration and Results system NCT06033755, date of registration: September12, 2023. Retrospectively registered.

A longitudinal follow-up of continuous laryngoscopy during exercise test scores in athletes irrespective of laryngeal obstruction, respiratory symptoms, and intervention.

BACKGROUND: Exercise-induced laryngeal obstruction (EILO) is diagnosed by the continuous laryngoscopy during exercise (CLE) test. Whether or how much CLE test scores vary over time is unknown. This study aimed to compare CLE test scores in athletes over time, irrespective of respiratory symptoms and grade of laryngeal obstruction. METHODS: Ninety-eight athletes previously screened for EILO were invited for a follow-up CLE test irrespective of CLE scores and respiratory symptoms. Twenty-nine athletes aged 16-27 did a follow-up CLE test 3-23 months after the baseline test. Laryngeal obstruction at the glottic and supraglottic levels was graded by the observer during exercise, at baseline and follow-up, using a visual grade score (0-3 points). RESULTS: At baseline, 11 (38%) of the 29 athletes had moderate laryngeal obstruction and received advice on breathing technique; among them, 8 (73%) reported exercise-induced dyspnea during the last 12 months. At follow-up, 8 (73%) of the athletes receiving advice on breathing technique had an unchanged supraglottic score. Three (17%) of the 18 athletes with no or mild laryngeal obstruction at baseline had moderate supraglottic obstruction at follow-up, and none of the 3 reported exercise-induced dyspnea. CONCLUSIONS: In athletes with repeated testing, CLE scores remain mostly stable over 3-24 months even with advice on breathing technique to those with EILO. However, there is some intraindividual variability in CLE scores over time. TRIAL REGISTRATION: ISRCTN, ISRCTN60543467, 2020/08/23, retrospectively registered, ISRCTN - ISRCTN60543467: Investigating conditions causing breathlessness in athletes.

Computational fluid dynamics of upper airway aerodynamics for exercise-induced laryngeal obstruction: A feasibility study.

Objective: Use of computational fluid dynamic (CFD) simulations to measure the changes in upper airway geometry and aerodynamics during (a) an episode of Exercise-Induced Laryngeal Obstruction (EILO) and (b) speech therapy exercises commonly employed for patients with EILO. Methods: Magnetic resonance imaging stills of the upper airway including the nasal and oral cavities from an adult female were used to re-construct three-dimensional geometries of the upper airway. The CFD simulations were used to compute the maximum volume flow rate (l/s), pressure (Pa), airflow velocity (m/s) and area of cross-section opening in eight planes along the vocal tract, separately for inhalation and exhalation. Results: Numerical predictions from three-dimensional geometrical modeling of the upper airway suggest that the technique of nose breathing for inhalation and pursed lip breathing for exhalation show most promising pressure conditions and cross-sectional diameters for rescue breathing exercises. Also, if EILO is due to the constriction at the vocal fold level, then a quick sniff may also be a proper rescue inhalation exercise. EILO affects both the inspiratory and the expiratory phases of breathing. Conclusions: A prior knowledge of the supraglottal aerodynamics and the corresponding upper airway geometry from CFD analysis has the potential to assist the clinician in choosing the most effective rescue breathing technique for optimal functional outcome of speech therapy intervention in patients with EILO and in understanding the pathophysiology of EILO on a case-by-case basis with future studies. Level of Evidence: 4.

Exercise-induced Laryngeal Obstruction: Protocol for a Randomized Controlled Treatment Trial.

BACKGROUND: Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathing problems in young individuals, caused by paradoxical inspiratory adduction of laryngeal structures, and diagnosed by continuous visualization of the larynx during high-intensity exercise. Empirical data suggest that EILO consists of different subtypes, possibly requiring different therapeutic approaches. Currently applied treatments do not rest on randomized controlled trials, and international guidelines based on good evidence can therefore not be established. This study aims to provide evidence-based information on treatment schemes commonly applied in patients with EILO. METHODS AND ANALYSIS: Consenting patients consecutively diagnosed with EILO at Haukeland University Hospital will be randomized into four non-invasive treatment arms, based on promising reports from non-randomized studies: (A) standardized information and breathing advice only (IBA), (B) IBA plus inspiratory muscle training, (C) IBA plus speech therapy, and (D) IBA plus inspiratory muscle training and speech therapy. Differential effects in predefined EILO subtypes will be addressed. Patients failing the non-invasive approach and otherwise qualifying for surgical treatment by current department policy will be considered for randomization into (E) standard or (F) minimally invasive laser supraglottoplasty or (G) no surgery. Power calculations are based on the main outcomes, laryngeal adduction during peak exercise, rated by a validated scoring system before and after the interventions. ETHICS AND DISSEMINATION: The study will assess approaches to EILO treatments that despite widespread use, are insufficiently tested in structured, verifiable, randomized, controlled studies, and is therefore considered ethically sound. The study will provide knowledge listed as a priority in a recent statement issued by the European Respiratory Society, requested by clinicians and researchers engaged in this area, and relevant to 5-7% of young people. Dissemination will occur in peer-reviewed journals, at relevant media platforms and conferences, and by engaging with patient organizations and the healthcare bureaucracy.

Breathing patterns in people with exercise-induced laryngeal obstruction.

Exercise-induced laryngeal obstruction (EILO) is common, but we lack readily available diagnostic tools. The larynx represents an important point of resistance in the airways, and we therefore hypothesized that EILO is associated with characteristic breathing patterns possible to record from a standard incremental ergospirometry test. We studied 24 individuals with moderate/severe EILO and 20 individuals with no-EILO, mean (SD) age 17 (6.1) and 24 (6.4) years, respectively. EILO versus no-EILO was verified from maximal continuous laryngoscopy treadmill exercise (CLE) tests, which also included ergospirometry. We described the relationships between minute ventilation ( V˙E ) versus tidal volume (VT ) and V˙E versus carbon dioxide output ( V˙CO2 ), using respectively quadratic and linear equations, and applied adjusted regression models to compare ergospirometry data and curve parameters. Compared to the no-EILO group, the group with EILO had prolonged inspiratory time (Tin ), lower breathing frequency (Bf ), lower V˙E , and lower inspiratory flow rate ( V˙in ) at peak exercise. Mathematical modeling of the breathing pattern relationships was feasible in both groups, with similar coefficients of variation. For V˙E versus VT , the mathematical curve parameters were similar. For V˙E versus V˙CO2 , the slope was similar but the intercept was lower in the EILO group. EILO was associated with prolonged Tin , lower Bf , V˙E , and V˙E . The relationship between V˙E versus VT was similar, whereas for V˙E versus V˙CO2 , the slope was almost parallel but shifted downward for the EILO group. Most ergospirometry data overlapped, except V˙in which discriminated between EILO and no-EILO in a promising way.

Exercise laryngoscopy in athletes and sportsmen: an easy way to assess exercise-induced laryngeal obstruction.

BACKGROUND: Exercise-induced laryngeal obstruction (EILO) is an exercise-dependent dyspnoea, linked to a laryngeal closure during physical effort. It may concern from 5% to 7% of adolescents and young athletic adults. EILO is a quite recently described condition: standardized diagnostic criteria and consensual management are still to come. Formal diagnosis of EILO requires a continuous laryngoscopy during exercise (CLE). This test allows visualization of laryngeal abnormalities during an effort but is only accessible in specialized centres. AIMS: We wanted to assess performance of a simplified CLE (sCLE) procedure for EILO diagnosis in everyday practice. MATERIAL AND METHODS: The procedure consisted in a continuous flexible videolaryngoscopy during a cycloergometre cardio-pulmonary exercise test. Screening questionnaire and visual scoring of laryngeal abnormalities were performed. Patients clinically suspected of EILO were included from 2018 to 2020. RESULTS: Seventeen consecutive subjects had an indication for sCLE. Fifteen patients underwent sCLE, and EILO-linked significative abnormalities were observed in 80% of them, thus confirming the diagnosis. CONCLUSIONS: CLE can be done successfully in a simple way. Due to its simplicity, tolerance and contribution in EILO diagnosis, this simplified version of CLE may promote its widespread use in ENT and pulmonology practices, as an affordable confirmation test.

Exercise Related Respiratory Problems in the Young-Is It Exercise-Induced Bronchoconstriction or Laryngeal Obstruction?

Complaints of breathlessness during heavy exercise is common in children and adolescents, and represent expressions of a subjective feeling that may be difficult to verify and to link with specific diagnoses through objective tests. Exercise-induced asthma and exercise-induced laryngeal obstruction are two common medical causes of breathing difficulities in children and adolescents that can be challenging to distinguish between, based only on the complaints presented by patients. However, by applying a systematic clinical approach that includes rational use of tests, both conditions can usually be diagnosed reliably. In this invited mini-review, we suggest an approach we find feasible in our everyday clinical work.

A systematic review of surgical treatment for supraglottic exercise-induced laryngeal obstruction.

OBJECTIVES: Exercise-induced laryngeal obstruction (EILO) is a condition causing breathing difficulties and stridor during exercise. The condition has in severe cases been treated surgically with supraglottoplasty. The purpose of this systematic review is to assess the evidence and recommendations for surgical intervention in treating patients with EILO. METHODS: A systematic search was performed in PubMed and Embase to identify relevant studies describing surgical treatment of patients diagnosed with severe EILO. According to eligibility criteria, data were independently extracted by two reviewers. To assess the risk of bias of each included study, the Newcastle-Ottawa scale (NOS) was used. RESULTS: The screening process identified 11 observational studies with a total of 75 patients. Findings indicated that many beneficial outcomes are to be found in surgical treatment for EILO. These indications were found both on visual verification of improvement of the laryngeal obstruction during exercise and patient self-reported symptom severity. The average NOS score (4.3) indicated low level of evidence in the included studies. CONCLUSION: Studies reporting effects of surgical treatment of EILO have shown promising results in patients with laryngeal obstruction. However, the heterogeneity of study methodologies and the level of evidence precludes definitive recommendations for or against supraglottoplasty at this time; prospective and methodologically robust studies are now needed. LEVEL OF EVIDENCE: 4.