Endoscopic surgery under tubeless anesthesia and spontaneous breathing for a congenital laryngeal web in an infant: A case report.

Congenital laryngeal webs are rare and are defined as thick epithelium-covered fibrous tissue lying between the vocal folds; the anterior glottis is the most common site of involvement, with possible extension to the subglottic region. The association with chromosome 22q11.2 deletion syndrome has also been reported. Symptoms have been abnormal or absent crying and airway obstruction since birth. Management strategies range from endoscopic division using cold instruments to open surgery for severe webbing. In endoscopic surgery, the need for tubeless anesthesia and spontaneous breathing is fundamental for obtaining the best surgical outcome. Here, we describe the case of a 4-month-old female patient affected by a type II glottic web according to Cohen, who was treated by simple endoscopic division in spontaneous breathing.

Swallowing Outcomes Following Supraglottoplasty: A Retrospective Review.

OBJECTIVES/HYPOTHESIS: Determine the incidence of short- and long-term dysphagia in pediatric patients with and without syndromes/neurodevelopmental delay following supraglottoplasty (SGP) at our institution. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective cohort study of children ≤18 years old who underwent SGP from 2014 to 2019 was undertaken. Age at surgery, sex, race, insurance, underlying syndromes/neurodevelopmental delay, concurrent surgical procedures, and clinical swallowing assessments were reviewed. Logistic regression was performed to identify factors associated with postoperative feeding difficulties. Time-to-event analysis was performed to assess time to resolution of dysphagia. RESULTS: A total of 231 patients were identified. Average age at time of SGP was 13.7 months. Of 231 patients, 88 (38.1%) had a syndrome/neurodevelopmental delay. Of these 231 patients, 112 had a preoperative videofluoroscopic swallow study or fiberoptic endoscopic evaluation of swallowing, of whom 53/112 (47.3%) had dysphagia. After SGP, 138/231 (59.7%) underwent clinical/instrumental swallowing assessments, of whom 95/138 (68.8%) had immediate postsurgical dysphagia. At last follow-up (1 month to 45 months), 15/95 (15.8%) had persistent dysphagia on instrumental assessment, 14/15 of whom had syndromes/neurodevelopmental delay. Time-to-event analysis revealed that for the nonsyndromic cohort, 25% had resolution of dysphagia by 4 months, 50% by 10 months, and 75% by 14 months. Cox proportional hazards regression revealed that the presence of underlying syndromes/neurodevelopmental delay was the only factor predictive of long-term postoperative dysphagia (hazard ratio of resolution 0.21 [95% confidence interval 0.096-0.48]). CONCLUSIONS: While short-term feeding difficulties following SGP in pediatric patients are not uncommon, long-term dysphagia is rare in patients without syndromes/neurodevelopmental delay. These data can be used when counseling caregivers about the risks and benefits of SGP. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2817-2822, 2021.

Symmetrical Apophyses on the Posterior Margins of the Thyroid Cartilage: A Previously Undescribed Anatomical Variation With Potential Forensic Implications.

Differential diagnosis between normal/variant anatomy and pathological/traumatic findings represents one of the main matters of investigation of the so-called forensic clinical anatomy. In the literature, many anatomical variations of the laryngeal thyroid cartilage have been reported, with potential implications in forensic pathology. They include triticeal cartilages, foramen thyroideum, asymmetry, segmentation or agenesis of the superior thyroid horns, bone connections with the hyoid bone, absence of cricothyroid facets, hypertrophy of the inferior thyroid tubercle, and asymmetries in the thyroid notch, isthmus, or length of the inferior horn. In this report, we describe a laryngeal anatomical variation never described before, consisting of 2 apophyses symmetrically arising from the posterior margins of the thyroid laminae. Postmortem computed tomography performed on the laryngeal visceral block excluded previous traumatic injuries or natural pathologies of the laryngeal cartilages, confirming the congenital origin of the finding. An "omega epiglottis" and 3 laryngeal cysts in the piriform sinuses also coexisted, suggesting the possibility of underlying common developmental mechanisms.

The effect of vocal fold augmentation on cough symptoms in the presence of glottic insufficiency.

OBJECTIVE: To determine the effect of injection augmentation of the vocal folds on chronic cough symptoms in patients with glottic insufficiency. METHODS: Medical records from 146 consecutive patients who underwent vocal fold injection augmentation by a fellowship-trained laryngologist between 2013 and 2015 were reviewed. Twenty-three patients (12 male) met inclusion criteria of a vocal fold augmentation injection, cough symptoms lasting more than 8 weeks, and glottic insufficiency as determined by shortened closed phase on stroboscopy. Exclusion criteria included lack of cough complaints, diagnosis of vocal fold immobility, previous history of vocal fold augmentation, and incomplete data sets. Data collected included age, gender, pre- and 1-month postinjection Cough Severity Index (CSI) scores, location of injection (unilateral or bilateral), and patient statement of percent change in symptoms that was recorded at 1-month postinjection visit. RESULTS: Paired t test indicated a significant decrease in CSI scores from pre- (m = 18.5) to 1-month postinjection (m = 12.1) (P = 0.004). Eighteen patients (78.2%) reported a 50% or greater improvement in cough symptoms at the 1-month postinjection visit. CONCLUSION: Injection augmentation of the vocal folds in the presence of glottic insufficiency appears to improve cough symptoms, as was reported by CSI in patients who are refractory to other medical and behavioral treatments. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1316-1319, 2018.

Airway Management in an Infant with a Large Supraglottic Mass after Failed Fiberoptic Intubation.

BACKGROUND: Fiberoptic bronchoscope-guided tracheal intubation is the gold standard for managing patients with supraglottic growths. In infants with a large and overhanging epiglottis, the success of fiberoptic-guided intubation relies heavily on the available space between the inferior surface of the epiglottis and the posterior pharyngeal wall or, more specifically, the superior surface of the supraglottic growth. CASE REPORT: We describe the inability to negotiate the tip of the fiberscope between the epiglottis and the supraglottic growth and the successful use of direct laryngoscopy to improve the available space along with the usefulness of "bubbling of air" to locate the glottic opening in an infant. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We emphasize the role of the emergency physician in managing such patients. Most of the time, the setting is not ideal in such emergency situations and the most qualified clinician to treat them is the emergency physician. The knowledge and skills of the emergency physician, along with awareness of the possible techniques for airway management, can be lifesaving.

Problemas del lenguaje en niños con parálisis cerebral / Language problems in children with cerebral palsy

La parálisis cerebral es una lesión no progresiva en las estructuras cerebrales que genera un trastorno del movimiento y de la postura. Estas lesiones también pueden afectar otras áreas responsables del desarrollo del lenguaje, tales como el sistema del habla, el sistema lingüístico o el procesamiento léxico, además de conllevar otras comorbilidades en diversas áreas. Objetivo. . Constatar el desarrollo del sistema lingüístico mediante la longitud media de los enunciados verbales y analizar el desempeño del procesamiento léxico que presentaron 142 niños mexicanos con parálisis cerebral cuyas edades comprendían de los 7 a los 13 años. Material y métodos. Mediante una elicitación de datos controlados la población debían nombrar 107 entidades clasificadas en 12 campos semánticos y contar el cuento Frog, Where are you? («Dónde está la ranita») siguiendo las imágenes de la historia para comprobar su longitud media de los enunciados verbales. Results. Solo el 16.9% de estos niños lograron nombrar más de 50 imágenes y contar el cuento que se les había mostrado. La longitud media de los enunciados verbales solo correspondió con la edad cronológica de un solo niño; el resto estuvo por debajo de lo esperado. El 83.1% de los 142 niños con parálisis cerebral evaluados no lograron emitir más de 10 palabras en ambas elicitaciones (AU)

Cerebral palsy is a non-progressive lesion in the brain structures that generates a disorder of movement and posture. These lesions can also affect other areas responsible for the language development system such as speech, linguistic or lexical retrieval system, as well as leading to other comorbidities in various areas. Objective. To observe the development of the language system using the Mean Length of Utterance and an analysis of the lexical retrieval presented in 142 Mexican children with cerebral palsy with ages ranging from 7 to 13 years. Material and methods. Using controlled data elicitation, the children with Cerebral Palsy were to name 107 entities (images) classified into 12 semantic fields and tell a story about «Frog, Where are you?», following the images of the story in order to check the Mean Length of Utterances. Results. Only 16.9% of these children were able to name more than 50 images that were shown and tell a story. The Mean Length of Utterance only corresponded with the chronological age in just one child, with the rest being lower than expected. The vast majority (83.1%) of the 142 children with palsy cerebral assessed did not exceed 10 words (AU)

Endoscopic management of congenital anterior glottic stenosis.

INTRODUCTION: Congenital anterior glottic stenosis (web) is a rare condition usually presenting with airway obstruction, stridor or dysphonia. Symptomatic infants may require tracheotomy to bridge the neonatal period. Early open surgical reconstruction may have significant risks and failure may still result in tracheotomy. We introduce an endoscopic surgical approach with balloon dilation for primary management of congenital anterior glottic stenosis. METHODS: We present three cases of congenital anterior glottic stenosis in children 7, 14, and 90 days old presenting with stridor, dyspnea, and dysphonia. The larynx was exposed by suspension microlaryngoscopy. The glottic stenosis was incised from a posterior to anterior direction using a laryngeal sickle knife. Subsequently, an airway balloon was guided through the stenotic lumen. Once the balloon was inflated, the balloon pressure was maintained for 30s or until the patient's oxygen saturation dropped below 92%. The dilation was repeated two or three times. The patients were kept intubated with an uncuffed endotracheal tube and monitored in the pediatric intensive care unit following surgery. RESULTS: All three patients were extubated within 72h without complications. One patient failed the first extubation attempt and was reintubated and successfully extubated 24h later. Patients were re-evaluated with direct microlaryngoscopy within two weeks. All patients had symptomatic relief and did not require further surgical intervention. CONCLUSION: Endoscopic balloon dilation laryngoplasty may be a safe and effective primary procedure for pediatric patients with congenital anterior glottic stenosis. It is technically simple and obviates the potential morbidities associated with an open surgical procedure or tracheotomy.

An index to objectively score supraglottic abnormalities in refractory asthma: learning, validation, and significance.

BACKGROUND: Patients with refractory asthma frequently have elements of laryngopharyngeal reflux (LPR) with potential aspiration contributing to their poor control. We previously reported on a supraglottic index (SGI) scoring system that helps in the evaluation of LPR with potential aspiration. However, to further the usefulness of this SGI scoring system for bronchoscopists, a teaching system was developed that included both interobserver and intraobserver reproducibility. METHODS: Five pulmonologists with expertise in fiber-optic bronchoscopy but novice to the SGI participated. A training system was developed that could be used via Internet interaction to make this learning technique widely available. RESULTS: By the final testing, there was excellent interreader agreement (κ of at least 0.81), thus documenting reproducibility in scoring the SGI. For the measure of intrareader consistency, one reader was arbitrarily selected to rescore the final test 4 weeks later and had a κ value of 0.93, with a 95% CI of 0.79 to 1.00. CONCLUSIONS: In this study, we demonstrate that with an organized educational approach, bronchoscopists can develop skills to have highly reproducible assessment and scoring of supraglottic abnormalities. The SGI can be used to determine which patients need additional intervention to determine causes of LPR and gastroesophageal reflux. Identification of this problem in patients with refractory asthma allows for personal, individual directed therapy to improve asthma control.

Flexible bronchoscopy as a valuable tool in the evaluation of infants with stridor.

The aim is to determine clinical characteristics, flexible bronchoscopy (FB) findings including associated airway abnormalities and other conditions, treatment modalities and long term follow-up of children with congenital stridor. Medical records of children, who underwent FB for the evaluation of stridor between 1 January 2004 and 31 December 2009 were retrospectively reviewed. Demographic characteristics, symptoms and physical examination findings at presentation, FB findings, follow-up data including the time to resolution of symptoms and treatment modalities, presence of associated conditions were assessed. 109 children were enrolled to the study. Laryngomalacia was the most common etiology for stridor. Laryngomalacia was isolated in 37 patients and 54 patients had secondary airway lesions (SALs). Diagnoses other than laryngomalacia such as subglottic hemangioma, subglottic web, isolated tracheomalacia were found in 18 patients. In 90 % of patients, stridor resolved before 3 years of age without any surgical intervention and there was no significant difference in terms of the persistence of stridor between patients with isolated laryngomalacia and associated SALs. Duration of stridor was significantly longer in both patients with neurological abnormalities and reflux symptoms. Surgical procedure was performed in 19 of the patients. There is a high incidence of SALs in patients with laryngomalacia. FB is helpful for identifying anomalies requiring surgical treatment.

Manejo de carcinoma glótico temprano: experiencia en el Hospital Universitario San Ignacio / Management of Early Glottic Cancer: Hospital Universitario San Ignacio Experience

Objetivos: Exponer la experiencia de la Unidad de Otorrinolaringología del Hospital Universitario San Ignacio en el manejo del cáncer glótico en estadios tempranos. Establecer la tasa de recurrencias y la calidad de la voz postratamiento. Diseño: Estudio descriptivo. Pacientes y métodos: Pacientes con cáncer glótico en estadios I y II, manejados con cirugía y/o radioterapia. Revisión de historias clínicas, 2004- 2012. Resultados: 63 pacientes con cáncer de laringe en estadios tempranos, 53 hombres y 10 mujeres, con edad promedio de 66,5 años; 48 recibieron manejo quirúrgico y 60 se trataron con radioterapia. 90% presentaron mejoría en el VHI y solo 10% sufrieron empeoramiento del mismo; la mejoría promedio fue de 19 puntos. En cuatro pacientes hubo recurrencia local y en dos a distancia. Conclusiones: Con el enfoque diagnóstico y terapéutico que realizamos en el Hospital San Ignacio, para el manejo del carcinoma glótico en estadios tempranos, hemos obtenido una adecuada tasa de curación de la enfermedad y mantenido una apropiada calidad de la voz postratamiento...

Objectives: To describe the experience of the ENT unit of the Hospital Universitario San Ignacio, in the management of glottic cancer in early stages with surgery and/ or radiotherapy. Establish the rate of recurrence and speech quality after treatment. Type of study: Descriptive study. Patients and Methods: Patients with glottic cancer at early stages managed with conservative surgery and/or radiotherapy. Medical charts of 2004 to 2012. Results: 63 patients with laryngeal cancer in the early stages (stages I and II), mean age 66.5 years. 48 patients underwent surgical treatment and 60 radiotherapy. Of the 31 patients, 28 showed improvement (90%) of de VHI and only 3 (10%) worsed, with an average improvement of 19 points. 4 patients developed local recurrence and 2 recurred in distance. Conclusions: The therapeutic approach in San Ignacio Hospital of glottic carcinoma stages I-II, obtained adequate cure rate with good voice quality after treatment...

Respiratory distress of the newborn: congenital laryngeal atresia.

Congenital laryngeal atresia is a rare cause of respiratory distress of the newborn. The defect may be isolated or occur in association with other congenital abnormalities, notably the presence of a tracheoesophageal fistula, esophageal atresia, encephalocele, or Congenital High Airway Obstructive Syndrome (CHAOS). We present the case of a newborn with no identified intrapartum abnormalities with respiratory distress at birth secondary to near-complete laryngeal atresia. Management included tracheostomy, repeated endoscopic incisions, and serial balloon dilatations employing the topical use of Mitomycin C. Seven year follow-up was significant for mobilization of the true vocal cords bilaterally, as well as successful decannulation.

Congenital glottic web: management and anatomical observation.

INTRODUCTION: Congenital anterior glottis web is a rare congenital laryngeal anomaly presenting usually by either dysphonia or airway obstruction. Several ways for managing this condition have been proposed including endoscopic, as well as external techniques. OBJECTIVE: The purpose of this study is to present our experience and to review the experience of others with cases of congenital glottic web regarding their diagnosis, classification and management. METHODS: It is a retrospective study, which included six infants and children; two groups were identified; first group included 3 patients who were treated by endoscopic laser lysis of webs, followed by topical application of mitomycin C (MMC) to the fresh wound, and the other group included 3 patients who underwent open surgical correction, by Laryngotracheal reconstruction (LTR). Information recorded included; age, sex, presentation, grading of lesions, surgery performed, residual web, and outcome. Assessment and documentation of subglottic extension independent from the glottic extension of the web was also done. RESULTS: All webs were grade 2, 3 and 4 according to Cohen's classification. We observed in five cases that high grade webs (grade 3 and 4) usually had thick subglottic extension, but in one case (case 2 laser) high grade web (grade 4) had thin subglottic extension. Complications included; two recurrences one after laser surgery and the other one after LTR. All appropriate patients were decannulated post LTR. CONCLUSION: Use of laser and MMC is good in thin glottic webs; LTR is indicated in glottic webs with thick subglottic extension. Not all high grade webs have thick subglottic extension. So, thickness of web and subglottic extension has to be assessed during microlaryngeal surgery, by laser incision and examination of web thickness to determine the appropriate management.

Endoscopic laser anterior commissurotomy for anterior glottic web: one-stage procedure.

OBJECTIVES: The conventional method for preventing web formation after anterior glottic web surgery is keel insertion. However, this presents risks of airway compromise and granulation tissue formation, which could necessitate tracheotomy in addition to a secondary procedure for keel removal. We introduce a novel, 1-stage endoscopic laser anterior commissurotomy for preventing anterior glottic web re-formation. METHODS: Twenty patients with glottic webs involving the anterior commissure were studied. The lesions were removed by transoral carbon dioxide laser microsurgery. In all patients, the anterior glottic web was vaporized along with the inner perichondrium of the thyroid cartilage over the anterior commissure area, creating a raw vertical break "alley" between the anterior vocal folds that measured between 0.3 and 0.5 cm in width and between 0.8 and 2 cm in length. The preoperative and postoperative vocal folds and voice quality were evaluated by videostrobolaryngoscopy and voice recordings. RESULTS: All 20 patients had anterior glottic webs ranging from 11% to 64% of the length from the anterior commissure to the vocal process. None of the patients developed restenosis at the anterior commissure of a severity similar to that of the initial lesion during follow-up (mean, 13 months; range, 3 to 44 months).All patients except 1 reported satisfaction with their voice improvement. Outcome analysis revealed that partial re-formation of the web was noted in 4 patients. CONCLUSIONS: One-stage, endoscopic laser anterior commissurotomy was effective and relatively safe for removing glottic webs, for preventing anterior glottic web re-formation, and for improving vocal fold performance among our patients.