Incidental Laryngeal Findings in Routine Laryngopharyngeal Reflux Diagnosis.

BACKGROUND: Laryngopharyngeal reflux (LPR) refers to the backflow of acidic stomach content into the larynx, pharynx, and upper aerodigestive tract. The diagnosis of LPR is based on the patient's history and findings of the laryngoscopy associated with LPR. Other possible manifestations consistent with LPR symptoms include laryngeal cancer, vocal fold granulomas, Reinke's space edema, and vocal polyps. In this study, we compared the characteristics of patients with LPR symptoms and incidental laryngeal findings (ILF) in the laryngoscopic evaluation to those without ILF (WILF). OBJECTIVES: Determine the characteristics of LPR-symptomatic patients with ILF versus WILF. METHODS: In this retrospective study, we examined 160 medical charts from patients referred to the otolaryngology clinic at Galilee Medical Center for LPR evaluation 2016-2018. The reflux symptoms index (RSI), reflux finding score (RFS), and demographics of the patient were collected. All patients with a positive RSI score for LPR (RSI > 9) were included, and the profiles of patients with versus without ILF on laryngoscopy examination were compared. RESULTS: Of the 160 patients, 20 (12.5%) had ILF during laryngoscopy. Most had vocal cord findings such as leukoplakia (20%), polyps (15%), and nodules (20%). Hoarseness, throat clearing, swallowing difficulty, breathing difficulties, and total RSI score were significantly higher in patients with ILF. CONCLUSIONS: Evaluation of LPR symptoms may provide otolaryngologists with a tool to identify patients with other findings on fiberoptic laryngoscopy. A laryngoscopic examination should be part of the examination of every patient with LPR to enable diagnosis of incidental findings.

DNA rare copy number alterations in Reinke's Edema.

INTRODUCTION: Reinke's Edema (RE) is a laryngeal lesion related to excessive tobacco smoking, voice overuse, and laryngopharyngeal reflux. Although the risk of malignancy has been considered low in literature, RE is classified among precancerous lesions. OBJECTIVES: We investigated DNA Copy Number Alterations (CNAs) in specimens of RE and its potential association with malignant progression. METHODS: We used array-based comparative genomic hybridization (aCGH, Agilent 4 × 180 K platform) to study eight RE cases. All patients were heavy tobacco users for at least 30 years, and none of them progressed to cancer in the follow-up (>8 years). Two RE presented mild dysplasia, one moderate dysplasia, and no histological alterations were found in the remaining five cases. CNAs were compared with the Database of Genomic Variants (DGV) and genes mapped on altered regions had their functions annotated. RESULTS: Six of eight patients showed different rare copy number alterations on chromosomes 2q37.3, 4q13.1, 4q13.3, 7q11.22, 10p14, and 13q34. A gain of the whole chromosome 8 were detected in one case. Of interest, four of eight RE cases showed copy number imbalances involving genes previously described in several tumor types (RASA3, COL6A3, LINC00707, LINP1, SMR3A, and SMR3B). CONCLUSION: The genomic imbalances herein found in RE have the potential to contribute to the phenotype but with limited or no risk of cancer. A long-term follow-up in a large series of patients could clarify the mechanisms involved in the malignant progression of RE.

A novel system that continuously visualizes and analyzes respiratory sounds to promptly evaluate upper airway abnormalities: a pilot study.

Although respiratory sounds are useful indicators for evaluating abnormalities of the upper airway and lungs, the accuracy of their evaluation may be limited. The continuous evaluation and visualization of respiratory sounds has so far been impossible. To resolve these problems, we developed a novel continuous visualization system for assessing respiratory sounds. Our novel system was used to evaluate respiratory abnormalities in two patients. The results were not known until later. The first patient was a 23-year-old man with chronic granulomatous disease and persistent anorexia. During his hospital stay, he exhibited a consciousness disorder, bradypnea, and hypercapnia requiring tracheal intubation. After the administration of muscle relaxant, he suddenly developed acute airway stenosis. Because we could not intubate and ventilate, we performed cricothyroidotomy. Subsequent review of our novel system revealed mild stridor before the onset of acute airway stenosis, which had not been recognized clinically. The second patient was a 74-year-old woman who had been intubated several days earlier for tracheal burn injury, and was extubated after alleviation of her laryngeal edema. After extubation, she gradually developed inspiratory stridor. We re-intubated her after diagnosing post-extubation laryngeal edema. Subsequent review of our novel system revealed serially increased stridor after the extubation, at an earlier time than was recognized by healthcare providers. This unique continuous monitoring and visualization system for respiratory sounds could be an objective tool for improving patient safety regarding airway complications.

Pre-tracheotomy for Potentially Emergent Airway Scenarios: Indications and Outcomes.

OBJECTIVES/HYPOTHESIS: Airway access in the setting of unsuccessful ventilation and intubation typically involves emergent cricothyrotomy or tracheotomy, procedures with associated significant risk. The potential for such emergent scenarios can often be predicted based on patient and disease factors. Planned tracheotomy can be performed in these cases but is not without its own risks. We previously described a technique of pre-tracheotomy or exposing the tracheal framework without entering the trachea, as an alternative to planned tracheostomy in such cases. In this way, a tracheotomy can be easily completed if needed, or the wound can be closed if it is not needed. This procedure has since been used in an array of indications. We describe the clinical situations where pre-tracheotomy was performed as well as subsequent patient outcomes. METHODS: Retrospective series of patients undergoing a pre-tracheotomy from 2015 to 2020. Records were reviewed for patient characteristics, indication, whether the procedure was converted to tracheotomy or closed at the bedside, and any post-procedural complications. RESULTS: Pre-tracheotomy was performed in 18 patients. Indications included failed extubation after head and neck reconstruction, subglottic stenosis, laryngeal masses, laryngeal edema, thyroid masses, and an oropharyngeal bleed requiring operative intervention. Tracheotomy was avoided in 10 patients with wound closed at the bedside; procedure was converted to tracheotomy in the remaining eight. There were no complications. Indications for conversion included failed extubation, intraoperative hemorrhage, significant stridor with dyspnea, and inability to ventilate. CONCLUSION: Pre-tracheotomy offers simplified airway access and provides a valuable option in scenarios where tracheotomy may, but not necessarily, be needed. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2802-E2809, 2021.

Predicting feeding tube and tracheotomy dependence in laryngeal cancer patients.

CONCLUSIONS: The two scales reliably measure laryngeal edema and dysfunction in laryngeal cancer patients. The eight categories from these scales, and abnormal pharyngeal squeeze, can be used to form a new rating scale intended to help clinicians identify and circumvent swallowing complications after chemo-irradiation. OBJECTIVES: The objectives were to compare two laryngeal edema rating scales in laryngeal cancer patients and determine if post-radiation +/- chemotherapy edema predicts dependence on a feeding tube and/or tracheostomy. METHODS: A retrospective chart review between 2005-2008 revealed 28 laryngeal cancer patients status post-radiation +/- chemotherapy, with video laryngoscopies performed within 6 months after treatment. Four raters evaluated videos based on the Laryngopharyngeal Edema Scale (LES) and the Reflux Finding Score (RFS). Tracheostomy and feeding tube outcomes were then correlated with the two scales. RESULTS: Feeding tube and tracheostomy dependence were associated with pre-treatment vocal cord paralysis, advanced T stage, and chemoradiation. Eight categories from the LES and RFS scales were significantly associated with the need for a feeding tube.

Manejo del fracaso de la extubación en la unidad de terapia intensiva pediátrica / Management of extubation failure in the pediatric intensive care unit / Gestão de falha de extubação na Unidade de Terapia Intensiva Pediátrica

El fracaso de la extubación es la incapacidad de tolerar el retiro del tubo endotraqueal con necesidad de reintubación. Puede ser causada por la obstrucción de la vía aérea superior y por la aspiración o la incapacidad de manejar las secreciones, factores que se evidencian al retirar el tubo. La reintubación por fracaso respiratorio post-extubación debe ser evitada en lo posible, ya que aumenta el riesgo de neumonía asociada al respirador, la estancia hospitalaria y en terapia intensiva, y la morbimortalidad. Describimos el manejo del fracaso de la extubación de causa laríngea en la Unidad de Terapia Intensiva de un hospital pediátrico.

Extubation failure is the inability to tolerate removal of the endotracheal tube with subsequent reintubation. It can be caused by obstruction of the upper airway and aspiration or inadequate clearance of airway secretion, factors that become evident when removing the tube. Reintubation due to postextubation respiratory failure should be avoided if possible because it increases the risk of ventilator associated pneumonia, hospital and intensive care unit stay, and morbidity and mortality. We describe the management of failed extubation due to laryngeal cause in the Intensive Care Unit of a pediatric hospital.

Falha de extubação é a incapacidade de tolerar a remoção do tubo endotraqueal na necessidade de reintubação. Ela pode ser causada por obstrução das vias aéreas superiores e aspiração ou incapacidade para lidar com secreções, factores que são evidentes para remover o tubo. Reintubação devido a insuficiência respiratória pós-extubação deve ser evitada, se possível, porque aumenta o risco de pneumonia associada à ventilação mecânica, permanência hospitalar e terapia, morbidade e mortalidade. Nós descrevemos a gestão de extubação falhou devido à causa da laringe na Unidade de Terapia Intensiva de um hospital pediátrico.

Angioedema hereditario / Hereditary angioedema

El angioedema hereditario es una enfermedad poco frecuente, con herencia autosómica dominante que se caracteriza por presentar edemas en piel y en la mucosa de diferentes órganos, fundamentalmente el tubo digestivo y el aparato respiratorio. Las manifestaciones clínicas pueden ser ligeras o graves, en dependencia de su intensidad y localización. Las formas más graves son el edema de la glotis y del tubo digestivo, que llegan a ocasionar síntomas como deshidratación intensa y dolor abdominal, el que puede confundirse con un abdomen agudo y llevar a una intervención quirúrgica innecesaria. El edema se caracteriza por no ser pruriginoso, no presentar aumento de la temperatura, no dejar godet al presionarlo y generalmente existen antecedentes familiares. No tiene predilección por sexo, ni por el color de la piel. Para su diagnóstico es necesario hacer un interrogatorio minucioso y exámenes complementarios del sistema complemento. Se han descrito dos formas clásicas denominadas angioedema hereditario tipo I y tipo II, el primero es el más frecuente. Recientemente se ha descrito el tipo III que se presenta solo en mujeres, sin alteración cuantitativa o cualitativa de C1-inhibidor y se asocia con el consumo de medicamentos o anticonceptivos orales que contienen estrógenos. El tratamiento se basa fundamentalmente en el uso de andrógenos atenuados o de los antifibrinolíticos, así como evitar los factores de riesgo en caso de que estos se conozcan. En los casos que presenten cuadros agudos se puede utilizar el plasma fresco congelado y un concentrado purificado de C1- inhibidor (Berinert-500) de uso endovenoso y de respuesta rápida; aunque sin ser muy efectiva se puede usar la epinefrina subcutánea. Los esteroides y los antihistamínicos no tienen ninguna efectividad en el tratamiento de estos pacientes(AU)

Hereditary angioedema is a rare disease with autosomal dominant inheritance that is characterized by edema in skin and mucosa of various organs, mainly gastrointestinal tract and the respiratory system. Clinical manifestations may be mild or severe, depending on their location and intensity. The most severe forms are edema of the glottis, and the edema of gastrointestinal tract which can cause severe dehydration and abdominal pain that can be confused with an acute abdomen and unnecessary surgery. The edema is characterized by not being itchy, no temperature rise, non-marking when pressed and usually have a family history. No predilection for sex, or skin color. Its diagnosis is necessary to make a thorough examination and additional tests of the complement system. They described two classic forms called HAE type I and type II, type I is the most common. Recently it described the type III that occurs only in females, without quantitative or qualitative alteration of C1 inhibitor and is associated with the consumption of drugs or oral contraceptives containing estrogen. The treatment is based primarily on the use of attenuated androgens or antifibrinolytic and avoiding risk factors if they are known. In cases of acute conditions present you can use fresh frozen plasma and purified C1 inhibitor concentrate (Berinert-500) for intravenous use and rapid response; but the use of subcutaneous epinephrine may not be very effective. Steroids and antihistamines have no effectiveness when used in these patients(AU)

Unusual foreign body in the larynx: a bee.

Foreign body lodgement in the larynx is a rare situation. Our review of the literature revealed no living foreign body in larynx except for laryngeal leeches and anisakiasis. In this article, we report a patient with unusual laryngeal foreign body lodgement: a bee which presented with sudden odynophagia and stinging sensation in throat. The bee was detected on the laryngeal mucosa in indirect laryngoscopic examination and removed immediately under general anesthesia in apneic period. In this case report, we describe the importance of detailed anamnesis and laryngeal examination even if the patient has no severe symptoms.

Dysphagia Caused by Chronic Laryngeal Edema.

A rare case of a young female with chronic diffuse laryngeal edema causing severe swallowing difficulty is presented. The patient was previously treated with antibiotics and steroids with no improvement. Diagnosis was made with biopsy of the epiglottis under local anesthesia in the office.

The incidence of premalignant and malignant disease in Reinke's edema.

Reinke's edema is a benign lesion of the vocal folds affecting the subepithelial space. As part of a study of the management of Reinke's edema, we aimed to determine the prevalence of dysplasia and malignancy in histologically proven Reinke's edema. A retrospective analysis of all laryngeal biopsies performed in north Glasgow, United Kingdom, between 2001 and 2010 was carried out. Clinical and pathological data from patients with histologically confirmed Reinke's edema were recorded with specific respect to the reporting of dysplasia and malignancy. From the 10-year cohort, a total of 3902 laryngeal biopsies were performed. In total, 189 patients (18 males and 171 females) had histologically proven Reinke's edema. Of this cohort, 170 (90%) had no dysplasia, 16 (8%) had mild dysplasia, 2 (1%) had moderate dysplasia, and 1 (<1%) had severe dysplasia. There was no malignancy reported. In our predominantly female smoking population, the epithelium appears to differentiate to benign Reinke's edema rather than malignancy. Patients can be reassured with regard to the low risk of malignancy in classic Reinke's edema.

[Obstructive laryngeal disease and obstructive sleep apnoea syndrome, a combination with serious peri-operative risk]. / Afección laríngea obstructiva y síndrome de apnea obstructiva del sueño, una asociación con severo riesgo perioperatorio.

We present the case of a patient who was diagnosed with chronic bronchitis, obstructive sleep apnoea syndrome, and large Reinke laryngeal oedemas that were removed by transoral laser microsurgery. In the immediate post-operative period acute respiratory insufficiency occurred due to pharyngeal collapse that required emergency re-intubation, after which the patient was transferred to the ICU where mechanical ventilation was given for 18h. Subsequent progress was normal. We describe the combination of various risk-factors related to anaesthetic management and the importance of considering each one of them, especially the preoperative detection of the severity of obstructive sleep apnoea syndrome.

Two cases of pharyngolaryngeal zoster advanced to multiple cranial neuropathy.

Varicella zoster virus (VZV) infection of the head and neck region may present with various symptoms. I present two cases of VZV infection of the pharynx and larynx with multiple cranial nerve neuropathies. Their initial symptoms such as sore throat, odynophagia, and dysphasia were complicated by otalgia, dizziness, hearing loss, or ipsilateral facial nerve paralysis. All of these lesions tended to lateralize to the ipsilateral side and endoscopic findings suggested VZV infections, which were confirmed by serial serologic examinations.

Multinodular thyroid goitre causing obstructive sleep apnoea syndrome.

BACKGROUND: Obstructive sleep apnoea syndrome has been linked to obesity, nasal obstruction and adenotonsillar hypertrophy, but rarely to large thyroid goitres. OBJECTIVE: To study the possible association between multinodular retrolaryngo-pharyngeal or retrosternal goitres and obstructive sleep apnoea syndrome. SUBJECTS AND METHODS: Retrospective case series at a tertiary referral centre (2000-2010). Study parameters included body mass index, Epworth sleep score and polysomnographic index. RESULTS: Five patients were diagnosed with obstructive sleep apnoea syndrome and managed with nasal continuous positive airway pressure ventilation. Computed tomography showed a retrolaryngo-pharyngeal or retrosternal goitre with significant tracheal compression, displacement and laryngeal oedema. After total thyroidectomy, obstructive sleep apnoea resolved in all patients. CONCLUSION: Large, multinodular goitres with retrolaryngo-pharyngeal extension can cause obstructive sleep apnoea syndrome due to laryngeal compression and oedema. In such cases, total thyroidectomy enables resolution of symptoms. Patients with obstructive sleep apnoea syndrome should be screened for thyroid goitre.

Laryngeal involvement in juvenile idiopathic arthritis patients.

Juvenile idiopathic arthritis (JIA) is an autoimmune diseases characterized by chronic arthritis and systemic manifestations. Autoimmune diseases can affect the upper airways including the larynx. The aim of this study was to investigate laryngeal involvement in JIA patients and its possible association with JIA disease parameters. Fifty consecutive JIA patients were screened for laryngeal abnormalities using flexible fiberoptic laryngoscope and laryngeal computerized tomography. Laryngeal abnormalities were detected in nine (18%) of our cases, with cricoarytenoiditis in six cases (12%) and a rheumatoid nodule in the pyriform fossa in only one case (2%). Diffuse congestion and edema of the posterior part of the larynx with normal vocal cord mobility was detected in two cases (4%). In our study, laryngeal abnormalities were significantly higher in patients with polyarticular seropositive disease subtype and also were significantly higher in patients with longer disease duration, higher disease activity scores, and those with erosive disease. JIA may affect the larynx. Laryngeal involvement in JIA patients is more in polyarticular seropositive cases. JIA patients have to be subjected to thorough otolaryngologic examination for early diagnosis and prompt management.

Chronic pharyngitis is associated with severe acidic laryngopharyngeal reflux in patients with Reinke's edema.

OBJECTIVES: We evaluated the association between pathological acidic laryngopharyngeal reflux (LPR) events and chronic pharyngitis in patients with Reinke's edema. METHODS: We performed a prospective controlled study in 20 consecutive patients with Reinke's edema without pathological acidic LPR events (group A) and 40 consecutive patients with Reinke's edema with both clinical symptoms and 24-hour pH-metry suggesting acidic LPR (group B). The severity of acidic LPR was assessed by use of the Reflux Finding Score (RFS), the Reflux Symptom Index (RSI), and dual antimony probe 24-hour pH-metry. The patients were evaluated for the presence of chronic pharyngitis by clinical examination and biopsy specimens taken from the posterior pharyngeal wall. The Chi2 test was used to compare the groups for the presence of pharyngitis. In group B, the RSI, the RFS, and the total duration and number of acidic LPR events on 24-hour pH-metry were compared between patients with and without concomitant pharyngitis by use of the Mann-Whitney test. RESULTS: Five patients of group A and 20 patients of group B had chronic pharyngitis. Therefore, more patients with Reinke's edema and clinical signs of LPR tended to have chronic pharyngitis than did those with Reinke's edema and no clinical signs of LPR, but the difference was not statistically significant (p = 0.064; odds ratio, 3.0; 95% confidence interval, 0.9 to 9.8). Among group B patients, those with pharyngitis had significantly more acidic LPR events (p < 0.001) and a greater exposure time to gastric fluid (p = 0.008) than did those without pharyngitis. Their RFS and RSI did not differ significantly (p = 0.692 and p = 0.914, respectively). CONCLUSIONS: Only in the subgroup of patients with Reinke's edema and LPR was there a statistically significant correlation between the pH probe results and the incidence of clinical pharyngitis. Awareness should increase among physicians about addressing chronic pharyngitis in therapy for acidic LPR and/or Reinke's edema.

Immediate postoperative airway obstruction secondary to airway edema following tumor excision from the neck.

A 46-year-old woman was scheduled for excision of a malignant peripheral nerve sheath tumor from the neck. The tumor had caused deviation of the trachea to the left and partial obstruction of the superior vena cava. Her upper airway at laryngoscopy after induction of anesthesia was normal. During tumor resection there were transient phases characterized by the complete disappearance of the peripheral oxygen saturation (Sp(O2)) and radial artery tracings. At the end of the operation, the trachea was extubated after ensuring adequate antagonization of neuromuscular blockade. However, immediately post-extubation, she showed signs of acute airway obstruction that necessitated reintubation of the trachea. Laryngoscopy revealed significant edema of the upper airway and vocal cords, requiring a smaller size tracheal tube. Many reports suggest the development of significant airway edema 24 h after such surgery. Our report highlights the fact that this can happen in the immediate postoperative period also. Some authors suggest that, in such surgery, extubation should routinely be done over pediatric tube exchangers. Routine leak testing and direct laryngoscopic/fiberoptic evaluation of the upper airway prior to extubation may also help. While our report reaffirms these points, it also stresses the importance of intraoperative monitoring for the compression of the great vessels, which may serve as a useful indicator of the early development of airway edema.

Unusual case of difficult double-lumen endotracheal tube removal.

A reusable Robertshaw red rubber double-lumen endotracheal tube (DLT) was placed to facilitate lung isolation for thoracoscopy in a 49-year-old atopic patient. In spite of its smooth insertion, it was then not possible to remove the DLT. Direct laryngoscopy showed severe laryngeal edema. After 48 hours of medical treatment with steroids, the trachea was extubated. The laryngeal edema could have been the result of physical and chemical irritation by the reusable rubber DLT itself, or from the substances formed during repeated cleaning and sterilization of the DLT. Atopic patients who are prone to developing latex allergy are also more liable to develop severe reactions to chemical, mechanical, and physical irritation from reusable red rubber DLTs or from the chemical solution used for its cleaning and sterilization.