Position paper of diagnosis and treatment of post-extubation laryngitis in children: a multidisciplinary expert-based opinion.

OBJECTIVES: To make recommendations on the diagnosis and treatment of post-extubation laryngitis (PEL) in children with or without other comorbidities. METHODS: A three-iterative modified Delphi method was applied. Specialists were recruited representing pediatric otolaryngologists, pediatric and neonatal intensivists. Questions and statements approached topics encompassing definition, diagnosis, endoscopic airway evaluation, risk factors, comorbidities, management, and follow-up. A consensus was defined as a supermajority >70%. RESULTS: Stridor was considered the most frequent symptom and airway endoscopy was recommended for definitive diagnosis. Gastroesophageal reflux and previous history of intubation were considered risk factors. Specific length of intubation did not achieve a consensus as a risk factor. Systemic corticosteroids should be part of the medical treatment and dexamethasone was the drug of choice. No consensus was achieved regarding dosage of corticosteroids, although endoscopic findings help defining dosage and length of treatment. Non-invasive ventilation, laryngeal rest, and use of comfort sedation scales were recommended. Indications for microlaryngoscopy and bronchoscopy under anesthesia were symptoms progression or failure to improve after the first 72-h of medical treatment post-extubation, after two failed extubations, and/or suspicion of severe lesions on flexible fiberoptic laryngoscopy. CONCLUSIONS: Management of post-extubation laryngitis is challenging and can be facilitated by a multidisciplinary approach. Airway endoscopy is mandatory and impacts decision-making, although there is no consensus regarding dosage and length of treatment.

Iron Pill-Induced Chemical Laryngitis.

OBJECTIVE: To discuss the presentation and management of pill-induced chemical laryngitis by illustrating a rare case. METHODS: We report a unique case of a patient with iron pill-induced laryngitis. RESULTS: A 71-year-old male presented for evaluation of dysphonia. Five weeks prior, the patient had reportedly aspirated an iron pill. The pill was lodged in his throat for several hours before being coughed up, soft but still intact. Since that event, the patient noted complete voice loss and in clinic was found to have a very breathy and asthenic voice. Stroboscopy revealed aperiodicity with severe false fold compression and significant ulceration of the infraglottic region associated with thick exudate. Vocal folds were mobile but atrophic, with overlying crusted secretions. A sensory deficit was suspected based on scope tolerance. The patient was treated with nebulized ciprodex and humidified air with some improvement in mucosal crusting but had persistent glottic insufficiency and dysphonia, prompting bilateral hyaluronic acid injection. CONCLUSIONS: Pill-induced laryngitis is an extremely rare phenomenon. While typically associated with bisphosphonates, this condition should be considered in any patient presenting with dysphonia and history of aspiration of a pill, including iron supplements. Regardless of the inciting medication, pill-induced laryngitis may be treated with humidified air, nebulized steroids, and antibiotics. Injection augmentation of the vocal folds may be made considered when glottic insufficiency and weak cough contribute to the presentation.

Primary fungal laryngitis mimicking recurrent laryngeal carcinoma.

A 79-year-old smoker with a background history of a treated glottic carcinoma and chronic obstructive pulmonary disease presented with progressive hoarseness, symptoms of aspiration and shortness of breath for 6 months. Examination revealed an ulcero-fungating mass over the posterior commissure of the larynx. A tracheostomy, direct laryngoscopy and biopsy of the mass was performed to secure his airway and to exclude recurrent glottic carcinoma. Reassuringly, a histopathological examination of the mass revealed numerous fungal yeast bodies. He was then treated with itraconazole for 4 weeks and was followed up as and outpatient with complete resolution and no recurrence of the disease.

Isolated Aspergillus Laryngitis: Spectrum, Management, and Review of Literature.

PURPOSE: Isolated aspergillus laryngitis is rare and often diagnosed after surgical excision or biopsy for a suspected premalignant or malignant pathology. Unlike other systemic or localized aspergillosis, there are no specific guidelines for isolated laryngeal aspergillosis. Our experience of dealing with a wide variety of isolated laryngeal aspergillosis showed that this entity is very responsive to medical therapy, making extensive debridement (as often carried out in surgically accessible aspergillosis) unnecessary as it would invariably lead to long-term dysphonia. MATERIALS AND METHODS: A retrospective analysis of all cases of isolated aspergillus laryngitis that presented to our hospital over the past 5 years was carried out. All patients with confirmed histopathological diagnosis of aspergillus infection were included. RESULTS: Twelve patients (five males and seven females) aged 28-54 years, who were diagnosed with aspergillus laryngitis presented with dysphonia. The most common involved site was the true vocal cords. All patients underwent cautious biopsies either in the operating theatre or in-office using a channeled fiber-optic laryngoscope. On histopathological examination, eight had invasive aspergillus infection while others showed variety of noninvasive involvement including colonization of cysts and carcinoma in situ. The most common species isolated was Aspergillus fumigatus. Appropriate antifungal chemotherapy was prescribed after ruling out systemic involvement. None of the patients showed recurrence or residual lesions on follow-up and reported significantly improved voice. CONCLUSIONS: This study highlights the wide spectrum of presentation of isolated aspergillus laryngitis with Aspergillus fumigatus being the most common organism isolated. Even the invasive variant is a medically treatable condition with voriconazole being the drug of choice. The importance of cautious biopsies and resections for voice preservation is also emphasized. To our knowledge, this is the largest report on isolated aspergillus laryngitis.

[Chronic catarrhal laryngitis in singers]. / Khronicheskii kataral'nyi laringit u vokalistov.

The article deals with optimization of treatment policy for singers with chronic catarrhal laryngitis. The survey sample is 51 singers with chronic catarrhal laryngitis of the age from 29 to 54 and the length of time worked from 8 to 22 years. The following methods are used: anamnesis, microbiological investigation, voice evaluation according to Visual Analog Scale (VAS), microlaryngoscopy, videolaryngostroboscopy, voice acoustic analysis (MDVP Kay Pentax system), statistical processing of results. It is shown that the cause of chronic catarrhal laryngitis in professional singers is non-bacterial irritants that provoke the appearance of an inflammatory process in the larynx, as well as uncontrolled use of drugs that irritate and dry out the mucous membrane and imperfect vocal technique. Pathogenic flora as an etiologic factor in the occurrence of laryngitis does not play an important role. A comprehensive treatment scheme for chronic catarrhal laryngitis using inhalation therapy and drugs that improve trophic processes in the laryngeal mucosa, which allows to increase the effectiveness of treatment and achieve stable remission of the disease, is suggested.

A case report of Talaromyces marneffei Oro-pharyngo-laryngitis: a rare manifestation of Talaromycosis.

BACKGROUND: The incidence of Taralomyces marneffei infection in HIV-infected individuals has been decreasing, whereas its rate is rising among non-HIV immunodeficient persons, particularly patients with anti-interferon-gamma autoantibodies. T. marneffei usually causes invasive and disseminated infections, including fungemia. T. marneffei oro-pharyngo-laryngitis is an unusual manifestation of talaromycosis. CASE PRESENTATION: A 52-year-old Thai woman had been diagnosed anti-IFNÉ£ autoantibodies for 4 years. She had a sore throat, odynophagia, and hoarseness for 3 weeks. She also had febrile symptoms and lost 5 kg in weight. Physical examination revealed marked swelling and hyperemia of both sides of the tonsils, the uvula and palatal arches including a swelling of the epiglottis, and arytenoid. The right tonsillar biopsy exhibited a few intracellular oval and elongated yeast-like organisms with some central transverse septum seen, which subsequently grew a few colonies of T. marneffei on fungal cultures. The patient received amphotericin B deoxycholate 45 mg/dayfor 1 weeks, followed by oral itraconazole 400 mg/day for several months. Her symptoms completely resolved without complication. CONCLUSION: In patients with anti-IFN-É£ autoantibodies, T. marneffei can rarely cause a local infection involving oropharynx and larynx. Fungal culture and pathological examination are warranted for diagnosis T. marneffei oro-pharyngo-laryngitis. This condition requires a long term antifungal therapy.

Hoarseness Guidelines Redux: Toward Improved Treatment of Patients with Dysphonia.

The Hoarseness Guideline Update provides an evidence-based approach to a patient who presents to the clinic with hoarseness. The guidelines cover management decisions in acute and chronic dysphonia for patients of all ages before and after laryngeal examination. The present review discusses the process used to develop these guidelines, including limitations of the process and each key action statement.

Post-transplantation laryngeal actinomycosis.

A case of laryngeal actinomycosis occurred after bone marrow transplantation was reported. The patient was a 14-year-old girl who had a history of bone marrow transplantation for the treatment of acute lymphocytic leukemia 4month before the onset of the disease. She was referred to our hospital complaining persistent sore throat since 2weeks ago. Fiberscopic observation proved the presence of white tumor-like mass on her right arytenoid of the larynx. As CT image demonstrated that the mass was localized at the arytenoid region with central low-density area surrounded by granulation tissue, we underwent biopsy under local anesthesia. Excision of the mass proved it to be a soft granulation including sulfur granules. Oral administration of amoxicillin 750mg per day was initiated as a postoperative medication. On day 17, histological study confirmed that the tumor-like mass was Actinomyces granuloma, and therefore amoxicillin administration continued. The medication was effective to subside the disease and the arytenoid lesion healed on day 31. Amoxicillin was further administered until day 70 to prevent recurrence. At 6month after the biopsy, she was free from the disease.

[Efficacy of systemic glucocorticoids combined with inhaled steroid on children with acute laryngitis].

Objective: To evaluate the efficacy of systemic glucocorticoid (steroid) combined with high dose inhaled steroid in the treatment of children with acute laryngitis. Methods: A total of 78 children with acute laryngitis were randomly divided into study group(n=40) and control group(n=38) between November 2016 and April 2017. In addition to routine treatment of anti infection and symptomatic treatment, Dexamethasone injection(0.3-0.5 mg/kg, 1-3 d, according to the patient's condition) was provided to each group. In addition to the treatment mentioned above, the study group were assigned to receive 1.0 mg Budesonide suspension for inhalation, oxygen-driven atomizing inhalation, every/30 minutes, 2 times in a row, after that every 12 hours. The improvement of inspiratory dyspnea, hoarseness, barking cough and wheezing of both groups was evaluated at 30 min, 1 h, 2 h, 6 h, 12 h, 24 h and 72 h after treatment.Sigmaplot 11.5 software was used to analyze the data. Results: No significant difference was detected in terms of inspiratory dyspnea, hoarseness, barking cough or stridor score before treatment between the two groups(P>0.05). Compared with those before treatment, symptoms of inspiratory dyspnea, hoarseness, barking cough and stridor score of both groups improved markedly at 12 h and 24 h after treatment(P<0.05). While there was no significant difference regarding inspiratory dyspnea, hoarseness, barking cough or stridor score at each time point after treatment between the two groups(P>0.05). The effective rate was 92.50% and 92.11% in study group and control group, respectively, and no significant difference was noted (P>0.05). Conclusion: Compared with single systemic glucocorticoid, systemic glucocorticoids combined with inhaled steroid possessed similar efficacy in treating acute laryngitis and relieving laryngeal obstruction of children.

MRSA chronic bacterial laryngitis: A growing problem.

OBJECTIVES: Chronic bacterial infection of the larynx is characterized by long-standing hoarseness and exudative laryngitis. Prolonged antibiotic therapy is required to clear the infection, and methicillin-resistant staphylococcus aureus (MRSA) may be the responsible pathogen. The objective of this study was to describe the presentation, comorbidities, treatment response, and underlying etiology- including the incidence of MRSA-in our patient population with chronic bacterial laryngitis. METHODS: A review of patients with a diagnosis of chronic bacterial laryngitis from 2012 to 2016 was performed. Diagnosis of chronic bacterial laryngitis was based on clinical history and findings on flexible laryngoscopy. In selected cases, the diagnosis of bacterial laryngitis was confirmed by operative biopsy. Information regarding clinical presentation and course was collected. RESULTS: Twenty-eight patients were included in the study. Twenty-three were treated empirically with Amoxicillin-clavulonic acid for a minimum of 21 days. Twelve of the 23 (52%) had recurrence or nonresolution of infection. Seven of the 12 nonresponders (58%) were found to have MRSA by laryngeal tissue culture. Five patients were treated initially with Sulfamethoxazole and trimethoprim, and all resolved the infection without the need for further treatment. There was a nonstatistically significant increase in smoking and reflux in the MRSA population compared to the non-MRSA group. CONCLUSION: MRSA infection was documented in 30% of patients overall with chronic bacterial laryngitis. Based on the results of the study, a treatment algorithm for management of this unusual patient population is suggested. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:921-925, 2018.

[The use of fenspiride for the combined treatment of exacerbation of chronic laryngitis]. / Fenspirid v kompleksnom lechenii obostreniia khronicheskogo laringita.

The present study was carried out based at the Department of Otorhinolaryngology of I.P. Pavlov First State Medical University of Saint-Petersburg. The objective of this work was to elucidate the efficacy and safety of fenspiride therapy for the treatment of exacerbation of chronic laryngitis associated with an acute respiratory infection. The patients comprising the main group received fenspiride (Eurespal, 'Servier', France) at the standard dose in addition to the conventional therapy with the use of antibiotics, inhalation, and voice rest. The patients in the group of comparison were treated following the conventional protocol without fenspiride. The clinical symptoms evaluated based on the scoring system, the results of videolaryngoscopy, and computer-assisted analysis of the voice were compared before and after treatment in the patients of both groups. The results of the study have confirmed the high effectiveness and safety of fenspiride therapy of exacerbation of chronic laryngitis.

[The prevalence of the fungal flora in association with chronic inflammatory pathology of the larynx]. / Rasprostranennost' gribkovoi flory pri khronicheskoi vospalitel'noi patologii gortani.

The present article was designed to analyze the prevalence and clinical features of laryngomycosis associated with chronic inflammatory diseases of the larynx. We examined 430 patients suffering from chronic pharyngitis and found the fungal flora in 100 (23.2%) of them. Diagnostics of the fungal infection was performed by the microscopic study of the stained preparations (including the Gram method, Romanovskiy-Giemsa and fluorescent microscopy). The sowing on elective nutrient media was used. The study revealed the presence of yeast fungi (Candida) in 98 patients (98%) and mold fungi (Aspergillus) in the remaining two (2%). The hyperplastic form of fungal pharyngitis was diagnosed in 55% of the patients. We have identified the following predisposing factors for fungal laryngitis: the gastroesophageal reflux disease in 56% of the patients, smoking in 50%, the long-term use of the removable dentures with the inadequate care for them in 30%, and the consistent use of inhaled corticosteroids in 27%. Hyperglycemia was documented in 6% and the history of long-term treatment with antibiotics in in 10% of the patients. The scheme for the combined antifungal therapy has been developed. Its practical application allowed to achieve the eradication of the fungal flora and to improve the clinical course of chronic laryngitis in 75% of the patients.

Facts and Fantasies on Extraesophageal Reflux: A Gastroenterologist Perspective.

Gastroesophageal reflux disease encompasses a wide spectrum of disorders related to the reflux of gastric contents into the esophagus. Extraesophageal reflux (EER) may be suspected in patients with unexplained chronic cough, pharyngolaryngeal symptoms, and asthma. For physicians, suspected EER is challenging as there is currently no tool that can reliably make a definitive diagnosis. Endoscopic signs are not specific, pharyngeal and proximal reflux monitoring are not reliable, and if distal pH or pH-impedance monitoring can identify patients with abnormal reflux, they cannot predict the response to therapy. Controlled randomized trials have failed to reliably demonstrate any benefit of high-dose proton-pump inhibitors over placebo in patients with laryngeal symptoms, chronic cough, and asthma. Overall, the role of gastroesophageal reflux has been largely overestimated in patients with suspected EER. Especially when proton-pump inhibitors failed to improve symptoms, other diagnosis should be considered, such as functional laryngeal disorders which are probably much more prevalent in these patients than pathologic gastroesophageal reflux.

Paraneoplastic mucous membrane pemphigoid with ocular and laryngeal involvement.

A 73-year-old woman was treated 8 years previously for synchronous breast and uterine neoplasms. She presented with a severe sore throat, odynophagia, dysphonia, dyspnoea, ocular irritation and weight loss over the last 3 months. Physical examination revealed ulcerations in the oral cavity, posterior pharyngeal wall and supraglottic larynx, nasal crusting, bilateral conjunctivitis and three cutaneous blisters. A diagnosis of anti-laminin 5 mucous membrane pemphigoid was retained, based on skin biopsy, direct immunofluorescence and immunoprecipitation. A positron emission tomography (PET)-CT detected multiple adenopathies. Cytology revealed adenocarcinoma with an immunocytology compatible with a breast origin and this was considered as a late metastatic recurrence of her previous breast cancer. A treatment of prednisone, dapsone and hormonotherapy was introduced, but intravenous immunoglobulin and rituximab were added due to new mucosal lesions. Despite treatment, a posterior laryngeal scar and bilateral symblepharon were developed. After 3 years, the patient is still alive and reports a satisfactory quality of life.

Antibiotic Prescribing for Nonbacterial Acute Upper Respiratory Infections in Elderly Persons.

BACKGROUND: Reducing inappropriate antibiotic prescribing for acute upper respiratory tract infections (AURIs) requires a better understanding of the factors associated with this practice. OBJECTIVE: To determine the prevalence of antibiotic prescribing for nonbacterial AURIs and whether prescribing rates varied by physician characteristics. DESIGN: Retrospective analysis of linked administrative health care data. SETTING: Primary care physician practices in Ontario, Canada (January-December 2012). PATIENTS: Patients aged 66 years or older with nonbacterial AURIs. Patients with cancer or immunosuppressive conditions and residents of long-term care homes were excluded. MEASUREMENTS: Antibiotic prescriptions for physician-diagnosed AURIs. A multivariable logistic regression model with generalized estimating equations was used to examine whether prescribing rates varied by physician characteristics, accounting for clustering of patients among physicians and adjusting for patient-level covariates. RESULTS: The cohort included 8990 primary care physicians and 185 014 patients who presented with a nonbacterial AURI, including the common cold (53.4%), acute bronchitis (31.3%), acute sinusitis (13.6%), or acute laryngitis (1.6%). Forty-six percent of patients received an antibiotic prescription; most prescriptions were for broad-spectrum agents (69.9% [95% CI, 69.6% to 70.2%]). Patients were more likely to receive prescriptions from mid- and late-career physicians than early-career physicians (rate difference, 5.1 percentage points [CI, 3.9 to 6.4 percentage points] and 4.6 percentage points [CI, 3.3 to 5.8 percentage points], respectively), from physicians trained outside of Canada or the United States (3.6 percentage points [CI, 2.5 to 4.6 percentage points]), and from physicians who saw 25 to 44 patients per day or 45 or more patients per day than those who saw fewer than 25 patients per day (3.1 percentage points [CI, 2.1 to 4.0 percentage points] and 4.1 percentage points [CI, 2.7 to 5.5 percentage points], respectively). LIMITATION: Physician rationale for prescribing was unknown. CONCLUSION: In this low-risk elderly cohort, 46% of patients with a nonbacterial AURI were prescribed antibiotics. Patients were more likely to receive prescriptions from mid- or late-career physicians with high patient volumes and from physicians who were trained outside of Canada or the United States. PRIMARY FUNDING SOURCE: Ontario Ministry of Health and Long-term Care, Academic Medical Organization of Southwestern Ontario, Schulich School of Medicine and Dentistry, Western University, and Lawson Health Research Institute.