An Overview of Laryngologic Manifestations of Neurologic Diseases.

PURPOSE OF REVIEW: Patients with various neurological disorders often present with or manifest during their disease process laryngologic pathology that can lead to significant morbidity. Recognizing and treating this aspect of their disease may be crucial in optimizing patient outcome. RECENT FINDINGS: We discuss updated information and management regarding various neurological disorders that affect the larynx and how these sequelae are diagnosed and treated. An understanding of the laryngologic manifestations of neurological disorders will facilitate management of these patient populations. Preventing and minimizing complications arising from these sequelae will improve quality of life and optimize patient outcomes.

The relation of recurrent laryngeal nerve to inferior thyroid artery and extralaryngeal nerve branching may increase the risk of vocal cord paralysis in thyroidectomy.

PURPOSE: The anatomical variations of the recurrent laryngeal nerve (RLN) are common during thyroidectomy. We aimed to evaluate the risk of RLN paralysis in case of its anatomical variations, retrospectively. METHODS: The patients with primary thyroidectomy between January 2016 and December 2019 were enrolled. The effect of age, gender, surgical intervention, neuromonitorisation type, central neck dissection, postoperative diagnosis, neck side, extralaryngeal branching, non-RLN, relation of RLN to inferior thyroid artery (ITA), grade of Zuckerkandl tubercle on vocal cord paralysis (VCP) were investigated. RESULTS: This study enrolled 1070 neck sides. The extralaryngeal branching rate was 35.5%. 45.9% of RLNs were anterior and 44.5% were posterior to the ITA, and 9.6% were crossing between the branches of the ITA. The rate of total VCP was 4.8% (transient:4.5%, permanent: 0.3%). The rates of total and transient VCP were significantly higher in extralaryngeal branching nerves compared to nonbranching nerves (6.8% vs. 3.6%, p = 0.018; 6.8% vs. 3.2%, p = 0.006, respectively). Total VCP rates were 7.2%, 2.5%, and 2.9% in case of the RLN crossing anterior, posterior and between the branches of ITA, respectively (p = 0.003). The difference was also significant regarding the transient VCP rates (p = 0.004). Anterior crossing pattern increased the total and transient VCP rates 2.8 and 2.9 times, respectively. CONCLUSION: RLN crossing ITA anteriorly and RLN branching are frequent anatomical variations increasing the risk of VCP in thyroidectomy that cannot be predicted preoperatively. This study is the first one reporting that the relationship between RLN and ITA increased the risk of VCP.

Clinical Prognosis of Vocal Cord Paralysis After Cardiothoracic Surgery in Infants.

We aimed to clarify the long-term outcomes and prognosis of vocal cord paralysis (VCP) after cardiothoracic surgery in infants as well as the usefulness of laryngeal ultrasound (LUS) as screening for VCP. Overall, 967 infants aged 1-year-old or younger who underwent cardiothoracic surgery between 2008 and 2022 were included in this study. We divided the patients into two groups based on the period on whether they underwent screening without or with LUS and compared the incidence of VCP between the groups. There were no differences in the patients' preoperative characteristics between the two periods, whereas the incidence of VCP was significantly higher in period 2 than in period 1 (11.0% vs. 3.2%, p < 0.0001). The incidence of VCP among the procedures, including aortic arch repair, was > 50% and significantly increased from period 1 to period 2. The sensitivity and specificity of LUS was 87% and 90%, respectively. Symptoms of VCP improved in 92% of patients. Repeated flexible laryngoscopy revealed that the residual rate of VCP was 68%, 52%, and 48% at 6, 12, and 24 months, respectively. In conclusion, symptoms of postoperative VCP improved in most cases; however, paralysis persisted in half of the patients. As a screening method, LUS is useful for evaluating postoperative VCP. A more accurate understanding of VCP is needed to improve postoperative outcomes.

Management of Implant Extrusion following Thyroplasty for Vocal Fold Paralysis: A Case Report.

The most widely used laryngeal surgery technique for patients with vocal fold paralysis is medialization thyroplasty. Materials such as Gore-Tex, silastic, and hydroxyapatite are often used, and the most worrisome possible complication is extrusion of the implant. A 36-year-old female patient with a history of pediatric cardiac surgery was diagnosed with left vocal cord paralysis after an episode of upper respiratory infection with a working diagnosis of subclinical left vocal cord paralysis following cardiac surgery. She underwent medialization thyroplasty with a Gore-Tex implant under local anesthesia. On the 21st postoperative day, she presented with sudden-onset hoarseness and dysphagia due to Gore-Tex implant extrusion. The implant was removed and augmentation of the left vocal cord with adipose tissue was performed. Only 14 cases of Gore-Tex implant extrusion have been described in the literature so far. The aim of this case report was not only to show one possible complication when using a Gore-Tex implant but also to present fat augmentation as one of the solutions for revision medialization and salvage treatment, with sustained long-term results.

Refining postoperative monitoring of recurrent laryngeal nerve injury in esophagectomy patients through transcutaneous laryngeal ultrasonography.

BACKGROUND: Recurrent laryngeal nerve injury (RLNI) leading to vocal cord paralysis (VCP) is a significant complication following minimally invasive esophagectomy (MIE) with upper mediastinal lymphadenectomy. Transcutaneous laryngeal ultrasonography (TLUSG) has emerged as a non-invasive alternative to endoscopic examination for evaluating vocal cord function. Our study aimed to assess the diagnostic value of TLUSG in detecting RLNI by evaluating vocal cord movement after MIE. METHODS: This retrospective study examined 96 patients with esophageal cancer who underwent MIE between January 2021 and December 2022, using both TLUSG and endoscopy. RESULTS: VCP was observed in 36 out of 96 patients (37.5%). The incidence of RLNI was significantly higher on the left side than the right (29.2% vs. 5.2%, P < 0.001). Postoperative TLUSG showed a sensitivity and specificity of 88.5% (31/35) and 86.5% (45/52), respectively, with an AUC of 0.869 (P < 0.001, 95% CI 0.787-0.952). The percentage agreement between TLUSG and endoscopy in assessing VCP was 87.4% (κ = 0.743). CONCLUSIONS: TLUSG is a highly effective screening tool for VCP, given its high sensitivity and specificity. This can potentially eliminate the need for unnecessary endoscopies in about 80% of patients who have undergone MIE.

Combined laryngeal framework surgery and cricopharyngeal muscle-origin transection: a novel effective surgery for dysphagia with pharyngolaryngeal palsy and cricopharyngeal dysfunction under local anesthesia.

BACKGROUND: Cricopharyngeal myotomy and laryngeal framework surgery can improve swallowing function in patients with severe dysphagia. We developed a novel surgical technique for severe dysphagia associated with pharyngolaryngeal paralysis and cricopharyngeal dysfunction, performed under local anesthesia, and investigated its effectiveness. METHODS: We included nine patients who underwent cricopharyngeal muscle-origin transection with laryngeal framework surgery through a horizontal skin incision under local anesthesia. CONCLUSIONS: All patients demonstrated significant improvement in the Food Intake LEVEL Scale without complications. Thus, this surgical technique may serve as a useful and less invasive treatment option for patients with severe dysphagia.

Surgical treatment and prognosis values of extranodal extension to recurrent laryngeal nerve in papillary thyroid carcinoma.

PURPOSE: Recurrent laryngeal nerve (RLN) invasion by extranodal extension (ENE) is a rare condition that may occur in papillary thyroid cancer (PTC), and it has never been characterised in the literature.Our research aims to investigate the clinical significance of ENE to RLN including its effect on vocal cord function, relationship with the aggressive behaviour of PTC, and optimal surgical methods. METHODS: A total of 3119 patients, including 2868 patients without RLN invasion, 251 patients with RLN invasion [categorised into the ENE invasion group (n = 55) and extrathyroidal extension (ETE) invasion group (n = 196)] were analyzed retrospectively. Data on clinicopathological characteristics, vocal cord paralysis (VCP), postoperative complications, surgical methods, rates of recurrence and metastasis were collected. Predictive disease-free survival (DFS) was analysed using the Kaplan-Meier method. RESULTS: The ENE invasion group showed a similar rate of VCP and DFS compared with the ETE invasion group (P = 0.15, P = 0.38, respectively). Sharp separation applied on the invaded nerves preserves the visual integrity of the RLN without significantly reducing the DFS (P > 0.05). ETE or ENE to RLN, lymph nodes metastasis (LNM), and T4 stage were independent factors for total recurrence [P = 0.04, hazard ratio (HR), 1.97 (1.04-3.75); P = 0.00, HR, 4.63 (2.24-9.54); P = 0.00, HR, 3.63 (1.94-6.77); P = 0.00, HR, 6.1 (3.24-11.50)]. RLN invasion, both by ETE or ENE, was significantly associated with reduced DFS (P = 0.00; P = 0.00, respectively). CONCLUSIONS: ENE to RLN, while rare, has not previously been well-studied. Our interesting premise and important findings including ENE to RLN has the same poor prognostic impact on recurrence as does invasion of the RLN by ETE and surgical management for the invaded RLN that preserves its visual integrity without compromising DFS. Those novel findings indicate that ENE to RLN could be considered as an additional factor beyond post-operative disease status and risk stratification, and it would be a valuable addition to further individualise treatment/surveillance for PTC.

An Analysis of Postoperative Complications in Medialization Thyroplasty: NSQIP Data.

INTRODUCTION: Medialization thyroplasty is a procedure indicated for treatment of impaired vocal fold movement. The purpose of this study was to identify variables associated with length of hospital stay (LOS), reoperation, and readmission in patients who underwent a medialization thyroplasty procedure for unilateral vocal cord paralysis. METHODS: Adults who underwent unilateral medialization thyroplasty were identified using the 2017 to 2019 NSQIP databases via Current Procedural Terminology code 31591. Data collected included patient demographics, comorbidities, preoperative labs, American Society of Anesthesiologists classification, inpatient status, operative length, and complications. Univariate and multivariate logistic regression were used to analyze effects on total LOS, reoperation, and readmission. RESULTS: 320 patients were identified, with a mean age of 61 years (95% Cl 59.4-62.7) and a female-to-male ratio of 1.1:1. Forty-two (13.1%) patients reported dyspnea as a preoperative symptom. Seven patients (2.2%) reported postoperative complications, 2 with multiple complications: 2 surgical site infections, 2 pneumonias, 2 unplanned intubations, 2 myocardial infarctions, 1 septic shock, 1 cardiac arrest, 1 ventilator use (>48 h), and 1 acute renal failure. Fifty-one (15.9%) were inpatient procedures, with a mean LOS of 1.43 days (95% CI 0.92-1.94). Preoperative functional status and bilirubin were significantly associated with longer LOS (p < 0.001). There were 6 (1.9%) readmissions and 2 (0.6%) reoperations. In univariate analysis, dyspnea varied with reoperation which is important to note in this patient population with glottic insufficiency. CONCLUSION: Medialization thyroplasty is a procedure with a low risk of mortality. However, preexisting patient comorbidities are associated with an increased risk of postoperative complications and an increased length of stay.

Don't go barking up the wrong tree: Thinking beyond infection in a toddler with stridor.

A toddler presented to the emergency department with persistent stridor and barky cough for 4 weeks and progressive dysphagia for 1 week. During this time, he had sought medical attention 6 additional times and had been treated for pneumonia, wheezing and croup, receiving antibiotics and several courses of steroids without improvement. On the final presentation, airway imaging did not reveal a foreign body. However, bedside laryngoscopy demonstrated bilateral vocal cord paralysis. Further imaging revealed an intracranial posterior fossa mass which provided the unifying diagnosis for his persistent symptoms.

Endoscopic percutaneous suture lateralization with syringe needles for neonatal bilateral vocal cord paralysis.

OBJECTIVE: To explore the novel technique of percutaneous endoscopic suture lateralization for bilateral vocal cord paralysis (BVCP) in neonates from Shenzhen, China, and to evaluate the safety and efficacy of the operation. METHODS: In this retrospective case series, we present four neonates with BVCP diagnosed within 3 days after birth from Shenzhen Children's Hospital. All had stridor, respiratory distress and hypoxemia requiring respiratory support at diagnosis. Endoscopic vocal fold lateralization was performed under general anesthesia using 3.0 mm endotracheal intubation through the improved technique of percutaneous needle-directed placement of a 4-0 Prolene suture, without the use of specialized equipment. A 4-0 Prolene wire was led out through two 10 ml syringe needles, the left vocal cord was fully moved and fixed under the skin with endoscopy monitoring. RESULTS: Overall, 3/4 of the patients showed clinical improvement in stridor and dyspnea 2-3 weeks after the operation and avoided a tracheostomy, two of them could breathe and feed normally when they were discharged from hospital, and one patient had a weak ability to suck but could breathe normally. The last patient had to undergo a tracheotomy due to the poor improvement in respiratory distress. None of the babies experienced any complications from this surgery, but case four presented with a series of complications and other problems in postoperative care related to the tracheostomy. At the last follow-up (mean 8 months), complete function of the bilateral vocal cords was acquired in case two (6 months) and partial function of the vocal cords was acquired in case one (13 months), with the other cases still experiencing paralysis. CONCLUSION: Endoscopic percutaneous suture lateralization may be a reversible, effective and minimally invasive primary treatment for neonatal BVCP. Most of neonates with BVCP undergoing this procedure avoided a tracheotomy.

Incidence and risk factor of vocal cord paralysis following slide tracheoplasty for congenital tracheal stenosis: a retrospective observational study.

BACKGROUND: Slide tracheoplasty for congenital tracheal stenosis (CTS) has been shown to improve post-operative outcomes, but the incidence and risk factors of vocal cord paralysis (VCP) following slide tracheoplasty remain unclear. This study aimed to review our experience of slide tracheoplasty for CTS with a focus on post-operative VCP. METHODS: Twenty-eight patients, who underwent tracheal reconstruction with or without cardiovascular repair at Kobe Children's Hospital between June, 2016 and March, 2020 were enrolled in this retrospective observational study. They were divided into two groups based on the presence of a pulmonary artery sling (PA sling). Perioperative variables were compared between the two groups. RESULTS: Twenty-one of the 28 patients underwent concomitant repair for associated cardiovascular anomalies, including 15 patients with PA sling. The overall incidence of VCP following slide tracheoplasty was 28.6%. The incidences of VCP were 46.7% in patients with CTS and PA sling, which were 14.3% in CTS patients without cardiovascular anomalies. The only risk factor associated with VCP following slide tracheoplasty was a concomitant repair for PA sling. Post-operatively, the duration of nasogastric tube feeding in patients with VCP was significantly longer than that in patients without VCP. CONCLUSIONS: The incidence of VCP following slide tracheoplasty for CTS was high, especially in concomitant repair cases for PA sling. Routine screening and evaluation of VCP soon after post-operative extubation is required for its appropriate management.

Laryngeal Dysfunction in Acute Organophosphorus and Carbamate Poisoning.

Background: Organophosphorus (OP) and carbamate pesticides are widely used for crop protection. We describe the spectrum of laryngeal abnormalities in patients admitted to the intensive care unit (ICU) with acute OP and carbamate poisoning as there is limited information on it. Materials and methods: Consecutive patients admitted to the ICU with acute OP and carbamate poisoning over 20 months (December 2014-July 2016) were recruited. Patients were followed up post-discharge if they had undergone tracheostomy or developed hoarseness of voice or stridor following extubation. Asymptomatic individuals who consented underwent laryngoscopy after ICU discharge. The primary outcome was the development of laryngeal dysfunction. Other outcomes included length of stay, need for ventilation, mortality, tracheostomy, and time to decannulation of tracheostomy. Results: Of the 136 patients recruited, 71 (52%) underwent laryngoscopy. The overall mortality rate was 9.6%. Of the 71 patients who underwent laryngoscopy, 18 had abnormal findings, which included unilateral or bilateral vocal cord paresis or palsy (n = 14) and/or aspiration (n = 9), subglottic stenosis (n = 1), tracheal stenosis (n = 1), or arytenoid granuloma (n = 1). Laryngeal dysfunction was associated with the ingestion of a dimethyl OP compound (p = 0.04) and quantum consumed (p <0.001). Patients with laryngeal dysfunction had significantly (p = 0.004) longer hospital stay (19.1 ± 10.7 vs 11.8 ± 8.3 days). Conclusion: Laryngeal dysfunction is not uncommon in OP and carbamate poisoning and is associated with the ingestion of larger quantity of a dimethyl OP compound and longer hospital stay. Otorhinolaryngologists could be involved early to help identify these abnormalities and initiate an appropriate treatment to ensure a functional voice and good airway. How to cite this article: Mani GS, Mathews SS, Victor P, Peter JV, Yadav B, Albert RRA. Laryngeal Dysfunction in Acute Organophosphorus and Carbamate Poisoning. Indian J Crit Care Med 2022;26(2):167-173.

RARE LARYNGEAL HAMARTOMA: A CASE REPORT.

Hamartoma (from the Greek language, where hamartia means defect or an error and -oma denoting a tumor or neoplasm) is a benign tumor-like mass composed of mature tissue or cells that are present in abnormal proportions or show a disorganized arrangement. Hamartomas are rarely seen in the head and neck area and especially rare in the larynx. Only few cases of laryngeal hamartoma have been reported in the literature so far. They are usually manifested by stridor, dysphonia and symptoms associated with airway obstruction. The diagnosis must be confirmed histologically and the method of choice in treatment is complete excision of the lesion. The authors present a case of laryngeal hamartoma of a 43-year-old woman treated for hoarseness and paralysis of the left vocal cord.

[Diagnostic efficiency of transcutaneous laryngeal ultrasound in assessing the mobility of vocal cord in patients with thyroid disease]. / Diagnosticheskaya effektivnost' ul'trasonografii gortani u patsientov s zabolevaniyami shchitovidnoi zhelezy.

OBJECTIVE: To assess the diagnostic efficiency of transcutaneous laryngeal ultrasound. MATERIAL AND METHODS: Ultrasound examination of the larynx and laryngoscopy was performed in 103 patients with thyroid disease. 26 (34.21%) patients who underwent surgery on the thyroid gland direct laryngoscopy and ultrasound of the vocal folds were performed twice, before and after the operation. RESULTS: Voice folds were visualized in 76 (73.8%) people. Of the 24 men, these anatomical structures were visualized in 8 (33.3%) and in 68 (86.1%) women out of 79 cases. Violations of the function of the vocal cords during laryngoscopy were detected in 5 people, sonographically in 6 people. The coincidence of the revealed pathology with ultrasound was in 4 patients, in 3 - with sonography the diagnosis was erroneous, in 1 patient it was falsely negative and in 2 cases it was falsely positive. CONCLUSIONS: In connection with the diagnostic capabilities of the method, it is advisable to use it as a screening study in the perioperative period in patients with diseases of the thyroid gland. Laryngoscopy is indicated for patients with non-visualized vocal folds, with identified pathology with ultrasound, and with clinical signs of dysfunction of the vocal cords.

Vocal fold injection material does not preclude interpretation of laryngeal electromyography.

INTRODUCTION/AIMS: Temporary vocal fold injection (VFI) is a common treatment for acute and subacute vocal fold paralysis (VFP). Laryngeal electromyography (LEMG) is useful for diagnosing neurogenic causes of VFP. This study evaluated whether the presence of VFI material prevents interpretation of LEMG in patients with acute and subacute VFP. METHODS: Patients with acute and subacute unilateral VFP (onset ≤6 mo) who underwent temporary VFI within 3 mo preceding LEMG were evaluated. A matched control group that did not undergo VFI was also studied. The LEMG team (laryngologist and electromyographer) performed and interpreted LEMG using a pre-specified protocol, including qualitative and quantitative motor unit analysis. RESULTS: Eighteen patients with VFI underwent LEMG successfully with interpretation of spontaneous activity and motor unit recruitment. Fourteen patients were seen in follow-up to determine accuracy of established LEMG prognosis. Seven of seven subjects with poor LEMG prognosis did not recover vocal fold motion. Five of seven subjects with fair LEMG prognosis recovered vocal fold motion. Findings were similar for the control group. DISCUSSION: VFI augmentation material did not prevent interpretation of meaningful LEMG data in patients with acute and subacute VFP, and accurate prognoses of vocal fold motion recovery were established.

Vocal cord paralysis following lithium button battery ingestion in children.

This study reports on vocal cord paralysis caused by esophageal button battery (BB) ingestion in children. Medical records of children with vocal cord paralysis and esophageal BB ingestion treated at a tertiary referral institute between January 2016 and March 2020 were reviewed. Five patients aged 9-58 months were identified; three were male. Each patient had accidentally swallowed a 20-mm-diameter lithium battery (3 CR2032 type and 2 CR2025 type). One battery was removed within 4 h after ingestion, and three batteries were removed within 12 h. Removal of the battery was achieved with rigid esophagoscopy in four patients and direct laryngoscopy in one patient. Four patients had bilateral, and one had unilateral vocal cord paralysis. Three patients underwent tracheotomy; two were tracheotomy-dependent until follow-up, while the third patient died of multiple organ dysfunction syndrome a month after surgery. The two cases without tracheotomy remain under close follow-up.Conclusion: Accidentally ingested button batteries should be removed promptly to avoid severe complications. Respiratory support and neurotrophic treatment in the early stage of vocal cord paralysis may be beneficial for recovery of vocal cord movement. What is Known: • Button battery ingestion in children is extremely harmful, especially when the diameter of the button battery exceeds 20 mm. • Esophageal button battery impaction can cause serious complications such as esophageal perforation, mediastinal infection, tracheoesophageal fistula, vocal cord paralysis, and life-threatening bleeding. What is New: • Vocal cord paralysis in children with button battery ingestion plays an early warning role for identifying the severity of the disease. • Early neurotrophic drugs and glucocorticoid therapy may be helpful for the recovery of vocal cord movement, thereby avoiding tracheotomy.

Pre- and post-operative high-speed videolaryngoscopy in unilateral vocal cord paralysis following autologous fat augmentation.

PURPOSE: To compare high-speed videolaryngoscopy (HSV) parameters such as open quotient (OQ), amplitude symmetry index (ASI), phase symmetry index (PSI), and frequency symmetry index (FSI), of the unilateral vocal cord paralysis (UVCP) patients pre and post (after 6 months) autologous fat augmentation. MATERIALS AND METHODS: This retrospective study evaluated all age and gender patients with UVCP that underwent autologous fat augmentation from July 2016 to July 2019. The OQ, ASI, PSI, and FSI were calculated from the HSV recordings by using the montage and fast Fourier transform point analysis. The pre-and post-operative means were compared using a paired student t-test, with a p-value less than 0.05 considered significant. RESULT: A total of 37 patients, age 41.2 ± 11.3 years (21 to 67 years), 59.4% females and 40.6% males, were included in the study. The average duration of symptom onset was 2.3 ± 0.87 months. The post-operative mean values of OQ, ASI, PSI, and FSI following the fat augmentation were significantly improved compared to the pre-operative mean values with p-values <0.0001, 0.0018, 0.0011, and 0.0006, respectively. CONCLUSION: There was a significant improvement in the OQ, ASI, PSI, and FSI in UVCP patients after 6 months of autologous fat augmentation, signifying an enhanced vibratory function. The ability of HSV to measure the minute details of vocal cord vibration by providing quantitative measurements has also been highlighted. The need for future prospective research with an increased sample size and longer duration of follow up is recommended.

Diagnostic accuracy of flexible fiberoptic laryngoscopy: experience from a tertiary health institution in Nigeria.

BACKGROUND: Flexible fibreoptic laryngoscopy (FFL) is a technique of laryngeal visualization. The instrument (flexible laryngoscope) is relatively scarce in resource challenged countries. Where available, it is a useful compliment to the armamentarium of clinical tools at the disposal of the otolaryngologist. We evaluated the diagnostic value of flexible fibreoptic laryngoscope in a tertiary health institution in Nigeria. And we hypothesized that its diagnostic precision is comparable to direct laryngoscopy. METHODS: This is a retrospective study of records of 360 patients referred for FFL at the ENT clinic. Sensitivity and specificity of FFL for laryngeal lesions were determined using direct laryngoscopy (DL) as the gold standard. RESULTS: Of the 360 FFL reports studied, 336 additionally underwent DL. FFL findings in 311 (92.6%) cases were comparable with that of DL. FFL had a good detection rate for vocal cord palsy (sensitivity 100%, specificity 80.7%). Pick-up rate for vocal nodules, polyps, papillomatosis and palsy were statistically equal for FFL and DL (p value = 0.96). Diagnostic accuracy of FFL was good for supraglottic (sensitivity 100%, specificity 88.0%) and glottic (sensitivity 100%, specificity 92.3%) tumours; relatively lower for subglottic (sensitivity 83.3%; specificity 100%) and transglottic (sensitivity 80.0%, specificity 100%) tumours; and least for tumours involving more than on subsites (sensitivity 50%, specificity 100%). CONCLUSION: The sensitivity and specificity of FFL were not the same for all endo-laryngeal lesions; yet, the overall diagnostic accuracy of FFL is comparable with DL. Clinicians should be mindful of this variability to optimize its application.

Laryngeal function in normal dogs administered isoflurane following partial clearance of alfaxalone or propofol.

OBJECTIVE: To assess laryngeal function in normal dogs administered isoflurane following partial clearance of alfaxalone or propofol. STUDY DESIGN: Randomized experimental crossover study. ANIMALS: A group of 12 purpose-bred, male Beagle dogs. METHODS: Dogs were randomly assigned to one of two treatments: alfaxalone-isoflurane (ALF-ISO) or propofol-isoflurane (PRO-ISO) and anesthetized for three video laryngoscopy examinations. The alternate treatment occurred after ≥ 14 days interval. Examinations were performed after induction of anesthesia (LS-A), after 20 minutes of breathing isoflurane via a facemask (LS-B) and after a further 20 minutes of isoflurane (LS-C). Parameters of objective laryngeal function included inspiratory rima glottidis surface area (RGSA-I), expiratory rima glottidis surface area (RGSA-E) and % RGSA increase, calculated from three consecutive respiratory cycles in the final 15 seconds of each video laryngoscopy examination. The % RGSA increase was calculated using [(RGSA-I - RGSA-E)/RGSA-E] × 100. Subjective laryngeal function was evaluated independently by two experienced surgeons blinded to treatment. RESULTS: The % RGSA increase within each treatment was greater for LS-B and LS-C than for LS-A (ALF-ISO: p = 0.03, PRO-ISO: p = < 0.001). There was no difference within each treatment from LS-B compared with LS-C. RGSA-I increased within each treatment from LS-A to both LS-B and LS-C (ALF-ISO: p = 0.002) and to LS-C (PRO-ISO: p = 0.006). Subjective laryngeal function scores improved from LS-A to LS-C. CONCLUSIONS AND CLINICAL RELEVANCE: Laryngeal function improved from postinduction examination following either 20 or 40 minutes of anesthesia with isoflurane via facemask. This study demonstrates that isoflurane may have a lesser effect on arytenoid abduction activity compared with more commonly used intravenous induction anesthetics (alfaxalone and propofol).

Bilateral vocal cord paralysis after endoscopic placement of fully covered self-expandable metal stent for palliative treatment of malignant proximal esophageal obstruction: two case reports.

BACKGROUND: Oesophageal stents have several well-known respiratory complications, including aspiration pneumonia, fistula and airway compression. However, bilateral vocal cord paralysis has rarely been described. METHODS: We describe two patients who presented with refractory dysphagia due to malignant proximal oesophageal strictures. Both received palliative treatment consisting of fully covered self-expandable metal stents that were placed across the strictures. RESULTS: Both patients developed inspiratory stridor and acute hypoxemic respiratory failure shortly after the stent was placed. Flexible bronchoscopy revealed vocal cord paralysis in paramedian position, potentially due to extrinsic compression of the posterior branch of the recurrent laryngeal nerve following the progressive opening of the esophageal prosthesis. One patient recovered after the stent was removed. CONCLUSIONS: Bilateral vocal cord paralysis is a rare but potentially fatal complication of proximal esophagus stenting.