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 inspiratory symptoms in school children.

BACKGROUND AND AIMS: Exercise-induced inspiratory symptoms (EIIS) have multiple causes, one of which is exercise-induced laryngeal obstruction (EILO). There is limited knowledge regarding EIIS in children, both in primary care practices and in pediatric asthma clinics. The aim of this study was to describe the feasibility of a diagnostic methodology and its results in a cohort of children with EIIS referred to our tertiary pediatric pulmonary center. METHODS: This study analyzed consecutively collected data in children from East Denmark and Greater Copenhagen referred during a 3½ years period. The continuous laryngoscopy exercise (CLE) test directly visualizes the larynx using a flexible laryngoscope during a maximal exercise test. A post-test questionnaire evaluated the subjective impact of the examination. RESULTS: The study included 60 children (37 girls/23 boys) with a mean age of 14 years (range 9-18). The feasibility of the CLE test was 98%; 18 children (35%) had EILO, while 33 children (61%) showed no abnormalities. Other laryngeal abnormalities were observed in three children before the exercise test. Asthma medication was successfully discontinued in 13 (72%) children with EILO. A significantly greater proportion of children shown to have EILO in the CLE test reported coping better with their EIIS than children with negative test (85% vs. 45%; P = 0.03). CONCLUSIONS: Continuous laryngoscopy during exercise is feasible and useful for identifying children with EILO. A correct diagnosis of EILO can help relieve patient anxiety, improve their coping with symptoms, and prevent unnecessary long-term and potentially harmful asthma treatments involving high-dose inhaled steroids. Pediatr Pulmonol. 2016;51:1200-1205. © 2016 Wiley Periodicals, Inc.

Larynx during exercise: the unexplored bottleneck of the airways.

Exercise-induced shortness of breath is not uncommon in otherwise healthy young people. Based on the presenting symptoms alone, it is challenging to distinguish exercise-induced asthma (EIA) from exercise-induced obstruction of central airways, sometimes leading to diagnostic errors and inadequate treatment. Central airway obstruction usually presents with exercise-induced inspiratory symptoms (EIIS) during ongoing exercise. EIIS tends to peak towards the end of an exercise session or immediately after its completion, contradicting symptoms of EIA typically peaking 3-15 min after the exercise has stopped. EIIS is usually associated with some form of laryngeal obstruction. Transnasal flexible laryngoscopy performed continuously throughout an incremental exercise test from rest to exhaustion or to intolerable symptoms is usually diagnostic, and also provides information that is important for further handling and treatment. Reflecting the complex anatomy and functional features of the larynx, exercise-induced laryngeal obstruction (EILO) appears to be a heterogeneous condition. Contradicting previous beliefs, recent literature suggests that laryngeal adduction in a majority of cases starts in supraglottic structures and that vocal cord adduction (VCD) most often occurs as a secondary phenomenon. However, EILO is poorly understood and more and better research is needed to unravel causal mechanisms. The evidence base for treatment of EILO is weak. Speech therapy, psychotherapy, biofeedback, muscle training, anticholinergic aerosols have all been applied, as has laser supraglottoplasty. Randomized controlled trials with well-defined and verifiable inclusion and success criteria are required to establish evidence-based treatment schemes.

Chondronecrosis of the larynx following use of the laryngeal mask airway.

This case describes the development of laryngeal chondronecrosis after use of the laryngeal mask airway (LMA). A 69-year-old male with prior laryngeal irradiation underwent total knee replacement with general anesthesia via LMA. Postoperatively, he developed laryngeal chondronecrosis, bilateral vocal fold immobility, and aspiration, necessitating tracheostomy and gastrostomy placement. He improved with hyperbaric oxygen therapy, intravenous antibiotics, and endoscopic repair of a residual fistula. Vocal fold motion returned and he was decannulated. Chondronecrosis of the larynx may occur with the use of the LMA, and caution should be used in patients with a history of prior laryngeal irradiation.

[Comparative results of conservative chemoradiotherapy and thermochemoradiotherapy for locally advanced laryngeal cancer].

There were analyzed results of treatment of 58 patients with laryngeal cancer T3-4N0-3M0. Chemoradiotherapy (CRT) was carried out in 27 patients, thermochemoradiotherapy (TCRT)-in 31 patients. Radiotherapy (RT) was performed in hyperfractionated mode (1 Gy + 1 Gy with an interval of 4-5 hours) 5 times a week to CTD 52-60 Gy with a 2-week break after CTD 30-40 Gy. Local hyperthermia (LHT) was carried out 2 times a week before the second fraction of RT in an amount of 3-6 sessions. The first cycle of polychemotherapy was administered at the beginning of RT and the second one-after the break. The local control under the primary tumor category T3 after CRT was equal to 58% and after TCRT--88%, at T4--72% and 25%, respectively. Late radiation damage of the larynx in the form of mucosal edema and perichondritis after CRT was in 2 patients (7%) and after TCRT--in 3 patients (10%). Thus, TCRT for locally advanced laryngeal cancer allows obtaining a higher overall survival and a local control as compared to CRT and does not lead to a significant increase of frequency of perichondritis.

[Neurolaryngology]. / Neurolaringología.

The neuroanatomy of voice and speech is complex. An intricate neural network is responsible for ensuring the main functions of the larynx: airway protection, cough and Valsalva production, and providing voice. Coordination of these roles is very susceptible to disruption by neurological disorders. Neurological disorders that affect laryngeal function include Parkinson's disease, stroke, amyotrophic lateral sclerosis, multiple sclerosis, dystonia and essential tremor. A thorough neurological evaluation should be routine for any patient presenting with voice complaints suggestive of neurogenic cause. Endoscopic visualisation of the larynx using a dynamic voice assessment with a flexible laryngoscope is a crucial part of the evaluation and ancillary tests are sometimes performed. Otolaryngologic evaluation is important in the diagnosis and treatment of neurological disorders that affect laryngeal function.

Impaired laryngeal mobility and entrapment neuropathies.

Entrapment neuropathies are rarely mentioned in phoniatrics because a definite diagnosis is very difficult to make. However, several clinical examples described here strongly support this etiology, which should now be considered in the diagnosis of both partial and complete laryngeal immobility as well as in minor neuromuscular disorders.

Silent reflux: ex juvantibus criteria for diagnosis and treatment of laryngeal disorders.

CONCLUSIONS: Some primary laryngeal pathologies with specific clinical presentation may be related to silent laryngeal reflux. An ex adjuvantibus proton pump inhibitor (PPI) treatment may be helpful for showing evidence of such a hidden laryngeal disorder. OBJECTIVE: To assess the validity of PPI as an ex adjuvantibus criterion for diagnosis and treatment of suspected reflux-associated laryngitis. PATIENTS AND METHODS: Sixty patients with clinical suspicion of laryngo-pharyngeal reflux (LPR) were identified on the grounds of laryngeal symptoms (dysphonia, cough, globus sensation, increased throat clearing, bad taste, and laryngeal spasm), laryngeal features (arytenoid edema/erythema, partial or total vocal fold erythema, and posterior glottic edema) with or without gastro-esophageal reflux disorder (GERD). They were consequently subdivided in three groups: type I, with LPR symptoms and features without GERD; type II with LPR symptoms and features with GERD; and type III with LPR features only. Types I and III were randomly treated with omeprazole (group A) or with immunostimulating vaccine (group B) for 3 months. Pre- and post-treatment laryngeal features and symptoms in all groups were evaluated by laryngo-stroboscopy and analyzed for statistical correlation. RESULTS: All omeprazole-treated patients showed improvement of laryngeal features and symptoms. With PPI treatment, a more significant improvement was noticed with respect to nonspecific immunostimulant therapy. Also, patients without LPR symptoms showed improvement of laryngeal features.

Inlet patch of gastric mucosa in upper esophagus causing chronic cough and vocal cord dysfunction.

BACKGROUND: An inlet patch of gastric mucosa in the upper esophagus is usually an incidental, congenital finding found during upper gastrointestinal tract endoscopy. Although it has been reported to cause dysphagia, strictures, adenocarcinoma, and webs, it has never been associated with cough and vocal cord dysfunction. OBJECTIVE: To report the first case of a patient with an inlet patch of gastric mucosa in the upper esophagus as the cause of a particularly troublesome, chronic cough that was initially missed on 2 upper endoscopies. METHODS: The patient is a 50-year-old man with a 7-year history of chronic cough associated with hoarseness, shortness of breath, and globus sensation. For diagnostic evaluation, pulmonary function tests, chest computed tomography, rhinolaryngoscopy, upper gastrointestinal tract endoscopy, and histologic examinations were performed. RESULTS: A multidisciplinary approach revealed several possible causes for the chronic cough, including vocal cord dysfunction, postnasal drip syndrome, allergic rhinitis, and mild gastroesophageal reflux disease that was only partially responsive to therapy. The results of 2 initial upper gastrointestinal tract endoscopies were interpreted as normal. A third endoscopy detected an inlet patch of gastric mucosa in the upper esophagus. Treatment with a high-dose histamine type 2 receptor antagonist and a proton pump inhibitor alleviated the patient's symptoms. CONCLUSIONS: An inlet patch of gastric mucosa in the upper esophagus is not uncommon, but it is often overlooked or believed to be an incidental, congenital finding. This is the first report, to our knowledge, of an inlet patch resulting in a troublesome, chronic cough.

Inspiratory muscle training in exercise-induced paradoxical vocal fold motion.

The purpose of the study was to determine if inspiratory muscle training (IMT) would result in increased inspiratory muscle strength, reduced perception of exertional dyspnea, and improved measures of maximal exercise effort in an athlete with exercise-induced paradoxical vocal fold motion (PVFM). The participant, an 18-year-old woman, had a 2-year history of acute dyspnea with exertion during soccer games. Spirometry, transnasal flexible laryngoscopy, and patient history supported a PVFM diagnosis. The ABAB within-subject withdrawal design study comprised IMT treatment and withdrawal phases, each lasting 5 weeks. The participant trained 5 days per week, completing five sets of 12 breaths at 75% maximum inspiratory pressure (MIP) per session. Data consisted of MIP, exertional dyspnea ratings, and maximal exercise measures. IMT resulted in increased MIP and decreased dyspnea ratings across both treatment phases. No change in MIP or dyspnea ratings occurred in response to treatment withdrawal. The maximal exercise test revealed minimal changes across phases. At end of the study, the participant reported experiencing no PVFM symptoms when performing the outcome measurement tasks and when playing soccer. Transnasal flexible laryngoscopy, after strenuous exercise and during rapid breathing and phonation tasks, revealed normal laryngeal findings. The findings suggest that IMT may be a promising treatment approach for athletes with exercise-induced PVFM.

Respiratory retraining of refractory cough and laryngopharyngeal reflux in patients with paradoxical vocal fold movement disorder.

OBJECTIVES/HYPOTHESIS: The objective was to describe a case series of patients with refractory cough and paradoxical vocal fold movement disorder treated with respiratory retraining therapy. STUDY DESIGN: Retrospective review of a case series in a tertiary medical care center. METHODS: Five patients with laryngopharyngeal reflux were identified with refractory cough and paradoxical fold movement disorder on transnasal fiberoptic laryngoscopy by a greater than 50% reduction in airway during inspiration. The were four women and one man (age range, 42-67 y). All patients had normal forced vital capacity and forced expiratory flow but decreased ratio of forced inspiratory volume at 0.5 seconds (FIV(0.5)) to forced inspiratory vital capacity (FIVC) before starting therapy. All patients were treated with more than 6 months of twice-daily proton pump inhibitor therapy with improvement in reflux symptoms but persistent and severe daytime cough. They were subsequently treated with respiratory retraining therapy. Patients were asked to rate subjectively the severity of cough at the onset and conclusion of therapy. All patients underwent pulmonary function testing before and after therapy. Long-term follow-up ranged from 5 to 17 months. RESULTS: Patients received two to seven sessions of respiratory retraining therapy. The mean severity score changed from 9.2 before therapy to 1.3 after therapy. All patients subjectively described an improvement in the severity of their cough. Transnasal flexible laryngoscopy demonstrated improvement in paradoxical vocal fold movement, and pulmonary function testing showed improvement in the FIV(0.5)/FIVC ratio. CONCLUSION: Patients with laryngopharyngeal reflux and refractory cough in the absence of pulmonary disease should be evaluated for paradoxical vocal fold movement disorder. Respiratory retraining therapy may represent an effective therapy for cough in the absence of relief from standard management of laryngopharyngeal reflux.

Laryngopharyngeal dysfunction from the implant vagal nerve stimulator.

OBJECTIVES/HYPOTHESIS: The objective of the study was to examine the side-effect profile of the vagal nerve stimulator. Vagal nerve stimulators have been used to treat intractable seizures in all age groups. They provide relief to the patient with a seizure disorder by decreasing the overall number and severity of seizure activities. Although significant complications are rare, many patients have some complaint, usually of their voice. STUDY DESIGN: A retrospective evaluation of four patients with intractable epilepsy. METHODS: Evaluation of charts and medical records and endoscopic examination of the larynx. RESULTS: In this small series, all four patients had implantation-related paresis. Three of the four appear to have side effects from device activation. CONCLUSIONS: Patients in whom a vagal nerve stimulator is placed can have adverse side effects. These can be related to the surgical manipulation of the vagus nerve, resulting in a temporary paresis of the vocal folds. A second set of side effects is related to the actual electrical stimulation of the device, and these side effects can directly affect the laryngeal musculature.

[Different therapeutic suggestions used in 4 types of laryngopathies presenting in professional singers]. / Suggestions thérapeutiques différentes appliquées à quatre types de laryngopathies présentées par des professionnels de l'expression chantée.

Four clinical cases involving non-surgical approaches to disorders usually treated surgically are considered. The emphasis is placed on the collaboration of artists with laryngologists combining their musical and medical training in their daily work at their office and an alternative clinical management of disorders.

Percutaneous dilatational tracheostomy in a patient with thyroid cancer and severe airway obstruction.

A patient with extensive metastatic thyroid cancer scheduled for palliative tracheostomy is presented. He had laryngeal dislocation with severe airway obstruction and few anatomical landmarks due to tumour infiltration and radiation. Successful percutaneous dilatational tracheostomy was performed under local anaesthesia.

Role of surgical techniques and operative findings in cranial and cervical nerve injuries during carotid endarterectomy.

OBJECTIVE: To establish the incidence of cranial and cervical nerve injuries during CEA and their relationship to different surgical techniques and operative findings. DESIGN: A prospective study. PATIENTS AND METHODS: From January 1994 to April 1995, 187 consecutive patients undergoing 190 CEAs were evaluated. Pre- and postoperative cranial and cervical nerve assessments were carried out by a single otolaryngologist, blinded to the operative technique and findings. Deficits lasting more than 12 months were defined as permanent. Logistic regression analysis was performed to evaluate the influence of surgical technique, type of anaesthesia, neck haematoma, and plaque extension on the onset of nerve injuries. RESULTS: Postoperatively, nerve lesions were identified in 51 CEAs (27%) and non-neurological injuries (hemilaryngeal ecchymosis or oedema) causing postoperative dysphonia were present in 80 CEAs (42%). All non-neurological injuries were transient and 98% disappeared within 1 month of surgery. Thirteen (7%) nerve lesions were permanent, but none were disabling. Vagus nerve lesions were significantly associated with long (> 2 cm) carotid plaque (OR = 3.5; CI 1.09-12.37; p = 0.03). Cervical branch lesions were associated with the presence of neck haematoma (OR = 1.9; CI 0.7-4.7; p = 0.05). The incidence of single cranial nerve injuries was higher in patch (OR = 2.7) and eversion (OR = 1.9) procedures than in primary closure. Multiple deficits (2 or more) were most frequent in eversion CEAs (OR = 2.8) and in cases complicated by neck haematoma (OR = 3.8). CONCLUSIONS: Cranial and cervical nerve lesions during CEA are common. However, our data showed that the majority of local complications are related to transient hemilaryngeal ecchymosis or oedema and, when permanent, are neither clinically relevant nor disabling at 1 year of follow up. Carotid plaque extension and neck haematoma appear to increase the incidence of cranial and cervical nerve lesions during CEA.

Comparison of intravenous ketorolac and alfentanil as supplements to propofol anesthesia for diagnostic panendoscopy.

STUDY OBJECTIVE: To determine if ketorolac tromethamine is an acceptable alternative to alfentanil as a supplement to propofol for diagnostic panendoscopy. DESIGN: Randomized, double-blind study. SETTING: University medical center. PATIENTS: 40 patients scheduled for panendoscopy and laryngeal tissue biopsy. INTERVENTIONS: Patients were randomly assigned to receive either alfentanil 14.5 micrograms/kg or ketorolac 1.0 mg/kg in a double-blind fashion, 5 to 10 minutes before induction of general anesthesia. MEASUREMENTS AND MAIN RESULTS: Heart rate (HR) and noninvasive blood pressure (BP) were measured and recorded before and immediately after injection of the study drug, after laryngoscopy for the endotracheal tube placement, and after initiation of diagnostic panendoscopy. Bleeding in the operative field was rated by the endoscopist. Observation from discontinuation of the propofol infusion and nitrous oxide inhalation to eye opening, head lifting, and orientation to time and place was observed and recorded. The presence of stridor after extubation, and pulse oximeter-determined arterial blood oxyhemoglobin saturation immediately after extubation and 5 minutes later, were noted. In the recovery room, the ability to tolerate oral fluids, sit, stand, and walk were recorded. Supplementation with ketorolac provides faster recovery from anesthesia as evidenced by shorter time to eye opening, head lifting, and orientation to time and place. However, no intergroup differences were found in measured intraoperative variables (BP and HR following laryngoscopy, tracheal intubation, diagnostic panendoscopy, and tissue biopsy). Operative site bleeding was comparable in both groups. The variables reflecting street readiness and the incidence of nausea and vomiting were statistically comparable. CONCLUSION: Supplementation of propofol anesthesia with ketorolac is an efficacious alternative to supplementation with alfentanil. The faster recovery in the ketorolac group is explained by the mostly peripheral effect of this drug, whereas the slow decline in the alfentanil concentration at the effective site may be responsible for slower emergence from anesthesia.