Narrative review of relationship between chronic cough and laryngopharyngeal reflux.

Gastroesophageal reflux disease (GERD) as a possible cause of chronic cough is known for decades. However, more than 75% of patients with extraoesophageal symptoms do not suffer from typical symptoms of GERD like pyrosis and regurgitations and have negative upper gastrointestinal endoscopy. For such a condition term laryngopharyngeal reflux (LPR) was introduced and is used for more than two decades. Since the comprehensive information on relationship between chronic cough and LPR is missing the aim of this paper is to summarize current knowledge based on review of published information during last 13 years. Laryngopharyngeal reflux is found in 20% of patients with chronic cough. The main and recognized diagnostic method for LPR is 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring, revealing reflux episodes irritating the upper and lower respiratory tract mucosa. The treatment of LPR should be initiated with dietary and lifestyle measures, followed by proton pump inhibitor (PPI) therapy and other measures. Despite progress, more research is needed for accurate diagnosis and targeted therapies. Key areas for exploration include biomarkers for diagnosis, the impact of non-acid reflux on symptom development, and the efficacy of new drugs. Further studies with a focused population, excluding other causes like asthma, and using new diagnostic criteria for LPR are essential. It's crucial to consider LPR as a potential cause of unexplained chronic cough and to approach diagnosis and treatment with a multidisciplinary perspective.

Clinical significance of type IV vascularization of laryngeal lesions according to the Ni classification.

Background: Scattered, small, dot-like intraepithelial papillary capillary loops (IPCLs) represent type IV epithelial vascularization according to "Ni classification" and are considered to be nonmalignant. According to the European Laryngological Society classification, these loops are malignant vascular changes. This contradiction has high clinical importance; therefore, clarification of the clinical significance of type IV vascularization according to the Ni classification is needed. Methods: The study was performed between June 2015 and December 2022. All recruited patients (n = 434) were symptomatic, with macroscopic laryngeal lesions (n = 674). Patients were investigated using the enhanced endoscopic methods of narrow band imaging (NBI) and the Storz Professional Image Enhancement System (IMAGE1 S). The microvascular patterns in the lesions were categorized according to Ni classification from 2011 and all lesions were examined histologically. Results: A total of 674 lesions (434 patients) were investigated using flexible NBI endoscopy and IMAGE1 S endoscopy. Type IV vascularization was recognized in 293/674 (43.5%) lesions. Among these 293 lesions, 178 (60.7%) were benign (chronic laryngitis, hyperplasia, hyperkeratosis, polyps, cysts, granulomas, Reinkeho oedema and recurrent respiratory papillomatosis); 9 (3.1%) were squamous cell carcinoma; 61 (20.8%) were mildly dysplastic, 29 (9.9%) were moderately dysplastic, 14 (4.8%) were severe dysplastic and 2 (0.7%) were carcinoma in situ. The ability to recognize histologically benign lesions in group of nonmalignant vascular pattern according to Ni (vascularization type I-IV) and distinguish them from precancers and malignancies was with accuracy 75.5%, sensitivity 54.4%, specificity 94.4%, positive predictive value 89.6% and negative predictive value 69.9%. Conclusion: Laryngeal lesions with type IV vascularization as defined by Ni present various histological findings, including precancerous and malignant lesions. Patients with type IV vascularization must be followed carefully and, in case of progression mucosal lesion microlaryngoscopy and excision are indicated.

Transnasal Endoscopic Pituitary Surgery-The Role of a CT Scan in Individual Tailoring of Posterior Septum Size Resection.

OBJECTIVE: This study was designed to evaluate the possibility of predicting the minimum size of septal resection for safe tumor extraction in transnasal paraseptal pituitary adenoma resection from preoperative computed tomography scans. METHODS: A retrospective CT scan analysis was performed on 20 patients who underwent endoscopic pituitary surgery at the University Hospital in Ostrava. Virtual insertion of the straight instrument into the sphenoid cavity was simulated using a CT scan. The minimum septal resection size was predicted and compared to various diameters in the nasal cavity. The results were then compared with cadaveric dissections, in which septal resections were performed at 1 cm and 2 cm distances from the anterior sphenoid wall. The association between cadaver dissections and CT scan results was studied. RESULTS: A total of 20 patients who underwent endoscopic transnasal surgery for pituitary adenoma between the years 2020 and 2021 were enrolled in the study. The mean virtual posterior septal size resection needed to reach the medial edge of the ICA with the straight instrument, without infracturing the nasal septum, was 13.2 mm. In cadavers with a 1 cm posterior septal resection, the medial edge of the ICA was reached with the straight instrument. In 2 cm resections, it was possible to reach beyond the lateral edge of the ICA. CONCLUSION: There is no significant correlation between the minimum septal size resection and measured diameters in the nasal cavity. According to our study, a 1 cm resection is sufficient for a non-extended pituitary tumor extraction. More extensive septal resections allow for better maneuverability and overview in the surgical field.

Chondrosarcoma of the Thyroid Cartilage Successfully Treated With Partial Resection of the Thyroid Cartilage.

Chondrosarcoma of the thyroid cartilage is a sporadic disease with nonspecific clinical presentation. Smooth swelling of the supraglottic area should arouse suspicion of possible pathology. In addition to laryngoceles, which usually do not have a significant impact, otolaryngologists should consider chondrosarcoma of the thyroid cartilage and indicate computed tomography (CT). Late diagnosis leads to worse prognosis, particularly worse voice after more extensive surgery, need for tracheostomy, and worse survival from higher degree chondrosarcomas.

Evolution of mucosal vasculature after radiotherapy of T1 vocal cord cancer: a pilot study.

PURPOSE: Narrow-band imaging is the state of the art in the diagnosis of mucosal lesions of the vocal cords. It is also used in the follow-up of patients after surgical therapy. Unfortunately, if a patient has received radiotherapy the follow-up is much more difficult. Radiation induces inflammatory changes in the mucosa, which lead to changes in the vascular architecture and thus affect the results of the examination. The dynamics and time dependence of vascular changes after radiotherapy have not yet been described. The purpose of this study is to describe the evolution of the vascular pattern in vocal cords after primary radiotherapy for glottic cancer. METHODS: This was a retrospective cohort study. Each patient underwent NBI videolaryngoscopy and was followed every 3 months. RESULTS: The tumor-related mucosal changes diminished at 3 months after radiotherapy. Afterward, growth of new longitudinal vasculature was observed and significantly slowed after 9 months. No perpendicular vasculature or tumor recurrence was observed during the course of the study. CONCLUSIONS: According to our data, we can conclude that post-radiation mucosal vasculature changes are only longitudinal.

Sleep Endoscopy with Positive Airway Pressure: A Method for Better Compliance and Individualized Treatment of Patients with Obstructive Sleep Apnea.

In this study, we aimed to observe the effects of positive airway pressure (PAP) on individual levels of obstruction during drug-induced sleep endoscopy (DISE) of the upper airways (UA), to evaluate at which pressures the obstruction disappeared or worsened, and to identify cases in which PAP was ineffective. This prospective study was conducted from June 2018 to June 2022. PAP testing was performed during DISE in patients with moderate and severe OSA. The pressure was gradually increased over the range from 6.0 to 18.0 hPa. Our findings were evaluated using the VOTE classification. The examination was performed in 56 patients, with a median apnea-hypopnea index (AHI) of 26.4. Complete obstruction of the soft palate was observed in 51/56 patients (91%), oropharyngeal obstruction in 15/56 patients (27%), tongue base obstruction in 23/56 patients (41%), and epiglottic collapse in 16/56 patients (29%). PAP was most effective in cases of complete oropharyngeal obstruction, and least effective in cases of epiglottic collapse, where it was ineffective in 11/16 patients. DISE with PAP is a simple diagnostic method that can be helpful for identifying anatomic and dynamic reasons for PAP intolerance. The main indication is ineffective PAP treatment.

Endoscopic two-port technique for orbital tumours: combined transnasal and sublabial approach.

INTRODUCTION: The aim of this study was to present the indications for a combined endoscopic transnasal and sublabial transantral approach for the surgical treatment of orbital lesions. MATERIAL AND METHODS: This case study enrolled 10 patients scheduled for endoscopic transnasal surgery for treating orbital lesions from 2009 to 2020. When the tumour was localised to the medial part of the orbit, patients underwent endoscopy with a transnasal mononostril approach. Alternatively, when the tumour was localised to the mediocaudal part of the orbit, and when instrument manoeuvreability was limited, the transnasal approach was combined with a sublabial transantral approach. Herein, we evaluate the indications, complications, and advantages of monoportal and combined two-portal approaches. RESULTS: 8/10 patients (80%) underwent surgery with the transnasal mononostril approach, and 2/10 (20%) underwent surgery with the combined transnasal mononostril and sublabial transantral approach. In the two latter cases, visualisation of the operation field was excellent, and there was adequate room for manipulating instruments. CONCLUSIONS: The combined mononostril-transantral approach provided the space necessary to manoeuvre instruments and to visualise the surgical field in treating mediocaudal orbital lesions. CLINICAL IMPLICATIONS: This two-portal approach enables extensive resections of intraconal lesions. It should be considered to be a suitable and safer alternative to the binostril approach.

Computational Fluid Dynamics Could Enable Individualized Surgical Treatment of Nasal Obstruction (A Preliminary Study).

Passage of nasal airflow during breathing is crucial in achieving accurate diagnosis and optimal therapy for patients with nasal disorders. Computational fluid dynamics (CFD) is the dominant method for simulating and studying airflow. The present study aimed to create a CFD nasal airflow model to determine the major routes of airflow through the nasal cavity and thus help with individualization of surgical treatment of nasal disorders. The three-dimensional nasal cavity model was based on computed tomography scans of the nasal cavity of an adult patient without nasal breathing problems. The model showed the main routes of airflow in the inferior meatus and inferior part of the common meatus, but also surprisingly in the middle meatus and in the middle part of the common nasal meatus. It indicates that the lower meatus and the lower part of the common meatus should not be the only consideration in case of surgery for nasal obstruction in our patient. CFD surgical planning could enable individualized precise surgical treatment of nasal disorders. It could be beneficial mainly in challenging cases such as patients with persistent nasal obstruction after surgery, patients with empty nose syndrome, and patients with a significant discrepancy between the clinical findings and subjective complaints.

Does Bicanalicular Intubation Improve the Outcome of Endoscopic Dacryocystorhinostomy?

The aim of this study was to compare the success of endoscopic dacryocystorinostomy with and without bicanalicular intubation in the treatment of distal nasolacrimal duct obstruction. METHODS: In a prospective, randomized, comparative study, endoscopic dacryocystorinostomy without bicanalicular silicone intubation (Group I) and endoscopic dacryocystorinostomy with intubation (Group II) were performed in patients with distal nasolacrimal duct obstructions. The tubes were removed 3 months after surgery in Group II, and the patients were followed up for 6 months after surgery. Therapeutic success was defined as the fluorescein dye disappearance test grade 0-1 corresponding with a complete resolution of symptoms. RESULTS: Thirty patients, aged 23-86 years, were included in the study. The success rate was 13/15 (86.67%) in Group I and in 14/15 (93.33%) in Group II. The difference between the two groups was not statistically significant (p = 0.483). Most common complications were granulations that occurred in 1/15 (6.67%) patient in Group I and in 2/15 (13.33%) patients in Group II. Adhesions in rhinostomy with epiphora and persistent secretion were observed in 1/15 (6.67%) patient in Group II. CONCLUSIONS: Bicanalicular intubation does not significantly increase the success rate of EDCR in distal nasolacrimal obstruction in adults.

Epiglottopexy Is a Treatment of Choice for Obstructive Sleep Apnea Caused by a Collapsing Epiglottis.

Drug-induced sleep endoscopy (DISE) reveals epiglottic collapse to be a frequent cause of obstructive sleep apnea (OSA) and intolerance of positive airway pressure (PAP). These patients require different management. This prospective study aimed to compare transoral laser epiglottopexy outcomes in patients with OSA caused by epiglottic collapse with the patients' previous PAP outcomes. Fifteen consecutive adult patients with OSA and epiglottic collapse during DISE were included; ten were analyzed. Before inclusion, PAP was indicated and ineffective in six patients, one of whom underwent unsuccessful uvulopalatopharyngoplasty. PAP was performed during DISE in all patients before epiglottopexy and was uniformly ineffective. ENT control was performed at 1 week and 1 month, and control limited polygraphy to 6 months after surgery. The apnea−hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) were significantly improved (p < 0.001 and p = 0.003, respectively) in all patients after epiglottopexy. Surgery was successful in 9/10 patients; the remaining patient had a significantly decreased AHI and could finally tolerate PAP. Transoral laser epiglottopexy is used to treat OSA in patients with epiglottic collapse. Unlike other methods, it significantly reduces both AHI and ESS and should be considered for these patients. An active search for OSA patients with epiglottic collapse is recommended to prevent treatment failure.

Internal Carotid Injury during Skull Base Surgery-Case Report and a Review of the Literature.

Iatrogenic injury of the internal carotid artery (ICA) is a rare, and probably underreported, complication of transnasal endoscopic skull base surgery. Although treatment algorithms have been suggested, there is no definite consensus or guideline for the management of this severe complication. We describe a case of ICA injury that occurred during a transsphenoidal biopsy of a tumor in the cavernous sinus and we present a treatment algorithm for managing this complication. We reviewed the articles published from 1998 to 2021, reporting on major vascular injury during transnasal endoscopic skull base surgery and endonasal endoscopic surgery, and we compare the methods and results of ICA injury management reported in the literature with the presented case. The most promising treatment for ICA injury might be packing with a muscle graft initially, then performing an endovascular intervention.

Solid Anorganic Particles and Chronic Rhinosinusitis: A Histopathology Study.

Although extensive research has shown the pathological effect of fine and ultrafine airborne particles, clear evidence of association of environmental exposure to them and inflammatory changes in human nasal mucosa is missing. Meanwhile, pathogenesis of chronic rhinosinusitis, despite being a disease with high prevalence in the population, is still unclear. The increasing evidence of the pro-inflammatory properties of these particles raises the question of their possible role in chronic rhinosinusitis. The presented study focused on detection of microsized anorganic particles and clusters of nanosized anorganic particles in the nasal mucosa of patients with chronic rhinosinusitis by Raman microspectroscopy and comparison of their composition to histologic findings. The results were compared to the findings in mucosa obtained from cadavers with no history of chronic rhinosinusitis. Solid particles were found in 90% of tissue samples in the group with chronic rhinosinusitis, showing histologic signs of inflammation in 95%, while in the control group, the particles were found in 20% of samples, with normal histologic findings in all of them. The main detected compounds were graphite, TiO2, amorphous carbon, calcite, ankerite and iron compounds. The results are in accordance with the premise that exogenous airborne particles interact with the nasal mucosa and possibly deposit in it in cases where the epithelial barrier is compromised in chronic rhinosinusitis.

Association Between Inferior Turbinate Hypertrophy and Extraesophageal Reflux.

Importance: To the authors' knowledge, no prior studies have examined the association between inferior turbinate hypertrophy (ITH) and extraesophageal reflux (EER). If EER were a cause or cofactor of ITH, antireflux treatment can be considered prior to surgical intervention. Objective: To evaluate EER presence and severity in patients with different degrees of ITH. Design, Setting, and Participants: Prospective multicentric cohort study conducted at 3 referral centers treating patients with EER and certified for 24-hour monitoring of oropharyngeal pH. The monitoring was performed between October 2020 and October 2021. A total of 94 adult patients with EER symptoms were recruited, 90 of whom were analyzed. Interventions: Nasal endoscopy was performed to determine the degree of ITH, according to the Camacho classification. Presence and severity of EER were examined using 24-hour monitoring of oropharyngeal pH. Main Outcomes and Measures: Primary outcomes were presence of EER according to RYAN Score, total percentage of time below pH 5.5, and total numbers of EER events below pH 5.5. Results: Of the 90 analyzed patients (median [IQR] age, 46 [33-58] years; 36 [40%] male patients), 41 had a maximum of second-degree ITH (group 1), and 49 patients had at least third-degree ITH (group 2), according to the Camacho classification. On the basis of the RYAN Score, EER was diagnosed more often in group 2 (69.4%) than in group 1 (34.1%; difference, 35.3% [95% CI, 13.5%-56.9%]). Moreover, compared with group 1, group 2 exhibited higher median total percentage of time below pH 5.5 (median [IQR], group 1: 2.1% [0.0%-9.4%], group 2: 11.2% [1.5%-15.8%]; difference, 9.1% [95% CI, 4.1%-11.8%]) and higher median total number of EER events (median [IQR], group 1: 6 [1-14] events, group 2: 14 [4-26] events; difference, 8 [95% CI, 2-15] events). Patients with proven EER demonstrated no difference in the degree of ITH between the right and left nasal cavity (Cohen g, -0.17 [95% CI, -0.50 to 0.30]), or between the anterior and posterior parts of the nasal cavity (Cohen g, -0.21 [95% CI, -0.50 to 0.17]). Conclusions and Relevance: In this cohort study, patients with a higher degree of ITH had more severe EER. A possible association between severe ITH and EER was demonstrated.

Fibroepithelial Polyp of the External Auditory Canal in a 2-Year-Old Child.

Here, we report a unique case in which a fibroepithelial polyp was found in the cartilaginous part of the external auditory canal of a 2-year-old child. The polyp was successfully treated by excision using an endaural approach and healed without complications. This is the very first report of a fibroepithelial polyp in the external auditory canal in the pediatric population. Although fibroepithelial polyp is an extremely rare diagnosis, it should be considered in the differential diagnosis of a child's external auditory canal polyp.

Narrative Review of Classification Systems Describing Laryngeal Vascularity Using Advanced Endoscopic Imaging.

Endoscopic methods are critical in the early diagnosis of mucosal lesions of the head and neck. In recent years, new examination methods and classification systems have been developed and introduced into clinical practice. All of these new techniques target the notion of optical biopsy, which tries to assess the nature of the lesion before histology examination. Many methods suffer from interpretation issues due to subjective interpretation of the findings. Therefore, multiple classification systems have been developed to assist the proper interpretation of mucosal findings and reduce the error rate. They provide various perspectives on the assessment and interpretation of mucosa changes. This article provides a comprehensive and critical view of the available classification systems as well as their advantages and disadvantages.

Identification of the phase composition of solid microparticles in the nasal mucosa of patients with chronic hypertrophic rhinitis using Raman microspectroscopy.

Solid particles, predominantly in micron and submicron sizes, have repeatedly been observed as a threat to a human health unique compared to the other textures of the same materials. In this work, the hypothesis the solid metal-based particles play a role in the pathogenesis of chronic hypertrophic rhinitis was investigated in patients who had not responded positively to medication. In the group of 40 randomly selected patients indicated for surgical mucotomy, the presence of solid micro- and submicron particles present in their nasal mucosa was assessed. For comparison, a set of 13 reference samples from patients without diagnosed chronic hypertrophic rhinitis was evaluated. The analysis was performed using Raman microspectroscopy. The advantage of this method is the direct identification of compounds. The main detected compounds in the mucosa samples of patients with chronic hypertrophic rhinitis were TiO2, carbon-based compounds, CaCO3, Ca(Fe, Mg, Mn)(CO3)2 MgCO3, Fe2O3, BaSO4, FeCO3 and compounds of Al and Si, all of which may pose a health risk to a living organism. In the reference samples, only TiO2 and amorphous carbon were found. In the control group mucosa, a significantly lower presence of most of the assessed compounds was found despite the longer time they had to accumulate them due to their higher mean age. Identification and characterisation of such chemicals compounds in a living organism could contribute to the overall picture of the health of the individual and lead to a better understanding of the possible causes not only in the chronic hypertrophic rhinitis, but also in other mucosal and idiopathic diseases.

Diagnosis of Laryngeal Pemphigus Vulgaris Can Be Facilitated Using Advanced Endoscopic Methods.

Background: Isolated laryngeal pemphigus vulgaris (LPV) is rare; however, early diagnosis is crucial in determining its course and prognosis. This paper aims to describe mucosal vascular changes typical for LPV using advanced endoscopic methods, which include Narrow Band Imaging (NBI), IMAGE1-S video-endoscopy and enhanced contact endoscopy (ECE). Materials and Methods: Retrospective analysis of all laryngeal mucosal lesion examined using advanced endoscopic methods during 2018-2020 at tertiary hospital was performed. Results: Videolaryngoscopy examination records of 278 patients with laryngeal mucosal lesions were analyzed; three of them were diagnosed with LPV. Epithelial vascularization of LPV included specific pattern. Intraepithelial papillary capillary loops were symmetrically stratified and were organized into "contour-like lines". This specific vascularization associated with LPV were different from other laryngeal mucosal pathologies. Conclusions: Using advanced endoscopic methods supports early diagnosis of LPV and accelerate the diagnosis and treatment.

Diagnostic Value of the PeptestTM in Detecting Laryngopharyngeal Reflux.

BACKGROUND: The PeptestTM is a non-invasive diagnostic test for measuring the pepsin concentration in saliva, which is thought to correlate with laryngopharyngeal reflux (LPR). The aim of this study was to investigate the diagnostic value of the Peptest in detecting LPR based on 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring using several hypopharyngeal reflux episodes as criterion for LPR. METHODS: Patients with suspected LPR were examined with the Reflux Symptom Index (RSI), Reflux Finding Score (RFS), fasting Peptest, and MII-pH monitoring. We calculated the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the Peptest, RSI, and RFS based on the threshold of one and six hypopharyngeal reflux episodes. RESULTS: Altogether, the data from 46 patients were analyzed. When one hypopharyngeal reflux episode was used as a diagnostic threshold for LPR, the accuracy, sensitivity, specificity, PPV, and NPV were, respectively, as follows: 35%, 33%, 100%, 100%, and 3%, for the Peptest; 39%, 40%, 0%, 95%, and 0%, for the RSI; and 57%, 58%, 0%, 96%, and 0%, for the RFS. The accuracy, sensitivity, specificity, PPV, and NPV of the Peptest for diagnosing gastroesophageal reflux disease (GERD) were 46%, 27%, 63%, 40.0%, and 48%, respectively. CONCLUSIONS: A positive Peptest is highly supportive of a pathological LPR diagnosis. However, a negative test could not exclude LPR.

Individualised Timing of Radio-Guided Parathyroidectomy Using Multi-Phase SPECT/CT Increases In Vivo Sensitivity and Accuracy and Reduces Operating Time: A Randomised Clinical Trial.

Background: Minimally invasive parathyroidectomy is the preferred treatment for primary hyperparathyroidism. Despite relatively accurate preoperative information, minimally invasive parathyroidectomy can be challenging, especially in the case of small and ectopic adenomas. Radio guidance aids in both in vivo identification and ex vivo confirmation of adenoma. In vivo accuracy is currently not satisfactory. The present study evaluated whether a beneficial effect (increased sensitivity, specificity, accuracy) is obtained with individualised timing of minimally invasive radio-guided parathyroidectomy (MIRGP) using preoperative multi-phase 99mTc-MIBI single photon emission computed tomography (SPECT)/computed tomography (CT). Methods: This randomised clinical trial was conducted from May 2016 to January 2020 in a tertiary referral hospital. Adult patients with primary hyperparathyroidism sent for 99mTc-MIBI SPECT/CT were included consecutively and randomly assigned to conventional (dual-phase) SPECT/CT and conventional MIRGP (group I) or multi-phase SPECT/CT and individualised MIRGP (group II). One hundred of 106 eligible patients were included, and 83 patients underwent complete intervention. Results: A total of 47 patients in group I and 35 patients in group II were analysed. Group II had a shorter operating time (p = 0.003). The in vivo sensitivity and accuracy of radio guidance was 85.1% in group I and 100% in group II (p = 0.046), and 90.4% in group I and 100% in group II (p = 0.021), respectively. We found no difference in the in vivo specificity and ex vivo parameters between groups. Conclusion: Individualised timing increased the in vivo sensitivity and accuracy of radio guidance and reduced operating time, as some parathyroid adenomas rapidly wash out the radionuclide.