Arytenoid asymmetry: Is it the most predictive parameter for arytenoid adduction in unilateral vocal fold paralysis?

OBJECTIVE: The aim of this study was to establish arytenoid asymmetry as a pre-operative predictive parameter for arytenoid adduction surgery in unilateral vocal fold paralysis and thereafter identify the most predictive parameter for arytenoid adduction among the established parameters. METHODS: A retrospective comparative study was undertaken. The 'arytenoid asymmetry angle' formed between skewed 'glottic' and 'interarytenoid' axes (traced along the plane of closure of the membranous and cartilaginous glottis, respectively) was quantified in pre-operative laryngoscopic images of 85 adults with unilateral vocal fold paralysis who underwent either type 1 thyroplasty (group 1) or type 1 thyroplasty with arytenoid adduction (group 2). The need for arytenoid adduction was determined intra-operatively based on subjective voice improvement and laryngoscopic results. RESULTS: Arytenoid asymmetry (p < 0.0001), posterior phonatory gap (p = 0.001) and vertical level difference (p = 0.004) were significantly greater in group 2 (descending order of parameters). Arytenoid asymmetry angle showed a significant positive correlation with the latter two parameters. CONCLUSION: Arytenoid asymmetry is the most predictive parameter for arytenoid adduction. An arytenoid asymmetry angle of more than or equal to 33.9° is an indication for arytenoid adduction. This aids in pre-operative planning of arytenoid adduction.

Redundant arytenoid mucosa: clinical presentation, treatment and outcome in three cats.

Three cats showing chronic, intermittent respiratory distress associated with increased noise on inspiration were examined. Head, neck and thoracic radiographs were unremarkable and laboratory findings were within normal ranges. In all three cats direct laryngoscopy revealed bilateral redundant arytenoid mucosa, which collapsed into the supraglottic and glottis airways during inspiration. Temporary tracheostomy and endoscopic diode laser excision of the excessive mucosa resolved symptoms in all three cats. Redundant arytenoid mucosa is a rare condition that may cause signs similar to laryngeal paralysis or laryngeal mass in cats. According to our results, diode laser surgery in association with temporary tracheostomy appears an appropriate mode of therapy.

The ram sign: detecting previously undiagnosed congenital laryngeal clefts in adults.

OBJECTIVES: We present the clinical characteristics of a case series of adult patients with type III laryngeal clefts according to the classification of Benjamin and Inglis, in an attempt to make practitioners aware of the "ram sign," a clinical finding associated with laryngeal clefts in adults. Laryngeal clefts are uncommon defects that are nearly universally identified during infancy as a result of persistent aspiration and pneumonia. Undiagnosed laryngeal clefts in adults are extremely rare. METHODS: Three type III laryngeal clefts were identified in adults (29, 48, and 60 years of age) from one clinic over an 18-month period. The existing literature features only one type III cleft, to our knowledge. The 60-year-old patient represents the oldest person in the English-language literature to have a newly diagnosed laryngeal cleft. All three cases presented with various degrees of aspiration over an extended period. RESULTS: The computed tomographic imaging and endoscopic findings from these three patients were reviewed. The videolaryngoscopic images demonstrated that the "ram sign"--an endoscopic finding associated with redundant soft tissue overlying the arytenoid cartilages that prolapses into the cleft, creating the appearance of ram's horns--was a consistent and striking feature in all three patients. CONCLUSIONS: Although rare, laryngeal clefts may represent an underdiagnosed entity in the adult population. With increased awareness, they may be identified more frequently as a treatable cause of aspiration and recurrent pneumonia.

[Surgical treatment of laryngomalacia in children]. / Leczenie operacyjne wiotkosci krtani u dzieci.

INTRODUCTION: Laryngomalacia is the most common congenital malformation of the larynx which causes stridor in newborns and infants. The stridor is inspiratory and it is first noted at birth but sometimes may not develop until 2 weeks of age. It increases in severity during crying, nursing, agitation, excitement and is made worse with head flexion or supination. Other symptoms such as supraclavicular, intraclavicular, intercostal and abdominal retractions may be associated. Boys are affected over twice as often as girls. Diagnosis of laryngomalacia is made by rigid or flexible laryngoscopy. Although this disorder is usually self-limited, in some cases the symptoms are so severe that operative intervention cannot be avoided. MATERIAL AND METHODS: Between 2002 and 2005, 13 infants were operated for severe form of laryngomalacia in the Pediatric ENT Dept in Poznan. In all patients the rigid or flexible laryngoscopy was performed to confirm the diagnosis. Then aryepiglottoplasty or epiglottoplasty were performed in all cases. It involved excision of the redundant mucosa over the arytenoid cartilages, the offending parts of he aryepiglottic folds, and trimming the lateral edges of the epiglottis, using microlaryngeal scissors and forceps. RESULTS: In all children symptoms such as: laryngeal stridor, feeding difficulties and dyspnea improved or completely resolved. In one case post-operative ventilation for several hours was required. All patients except one demonstrated significant airway improvement in the immediate postoperative period. CONCLUSIONS: Direct laryngoscopy must be performed prior to the aryepiglottoplasty to decide what amount of tissue to resect. Endoscopic aryepiglottoplasty with use of microlaryngeal instruments is an effective and safe method of the treatment of severe form of laryngomalacia. It is better to perform this procedure in general anesthesia without intubation.

A rudimentary epiglottis associated with Pierre Robin sequence.

Epiglottis anomaly associated with Pierre Robin sequence (PRS) is a rare occurrence. To the knowledge of the authors, this is the first reported case of epiglottic anomaly associated with PRS. Doctors should remain aware of this atypical presentation in a PRS patient, and the presented case highlights the clinical challenges that must be met to ensure effective treatment of the defect in terms of compromised respiration, swallowing and feeding.

Exercise-induced stridor due to abnormal movement of the arytenoid area: videoendoscopic diagnosis and characterization of the "at risk" group.

We evaluated 4 patients who developed severe, symptomatic stridor during maximal cardiopulmonary exercise testing, all referred due to exercise-related dyspnea. All underwent resting, unsedated transnasal fiberoptic laryngoscopy and had normal findings. Four patients performed repeat maximal exercise testing with fiberoptic laryngoscopy, and they form the basis of this report. They had normal vocal cord motion during exercise, but developed abnormal anterior motion of the arytenoid and aryepiglottic folds only at peak exercise, leading to partial airway obstruction and severe stridor. This report details the workup and characterizes patients at risk for this unusual phenomenon.

Idiopathic mucosal lesions of the arytenoid cartilages of 21 Thoroughbred yearlings: 1997-2001.

REASONS FOR PERFORMING STUDY: Mucosal ulcers and, occasionally, small granulomas on the axial surface of one or both arytenoid cartilages have been found in TB yearlings presented for post sale endoscopic examination. OBJECTIVES: To determine the incidence, endoscopic characteristics and outcome of a group of Thoroughbred yearlings affected with mucosal ulcers and granulomas of the arytenoid cartilage. HYPOTHESIS: The incidence of mucosal ulceration of the arytenoid cartilages of yearling Thoroughbreds is relatively high compared to other upper airway abnormalities; and that the majority of mucosal ulcers heal uneventfully, although a small percentage may progress to a granuloma and, less commonly, to arytenoid chondropathy. METHODS: The findings of post sale, upper airway endoscopic examinations of 3312 Thoroughbred yearlings, during a 5 year period, were reviewed, including those abnormalities listed in the conditions of sale and others not listed but considered likely to cause airway obstruction. Information obtained from the medical record of horses that had mucosal ulceration or granuloma of the arytenoid cartilage included the location and size of the lesion(s), sex of the affected horse and the presence and nature of other concurrent abnormalities of the upper portion of the respiratory tract. Additional information included treatment and results of follow-up, endoscopic examination by the authors or attending veterinarian. RESULTS: Mucosal lesions were seen in 0.63% of yearlings evaluated, which represented the most common, documented condition of the upper portion of the respiratory tract. The mucosal ulcers of 15 of 19 horses were considered to have healed without complication during follow-up examination; one of the 19 horses was lost to follow-up. Two horses affected with bilateral, arytenoid mucosal ulceration developed a granuloma at each site of ulceration. One horse developed a granuloma at a site of ulceration and, subsequently, arytenoid chondropathy. CONCLUSIONS: Arytenoid mucosal ulceration in sales yearlings was a relatively commonly encountered abnormality and a small percentage progressed to granuloma or chondropathy. POTENTIAL RELEVANCE: The mucosa of the arytenoid cartilage, particularly at the rostral margin of the vocal process, should be examined carefully during endoscopic examination of the upper portion of the respiratory tract of Thoroughbred yearlings presented for sale. Because a small percentage of mucosal ulcers may progress to granuloma or, less commonly, chondropathy, identification of mucosal ulcers of the arytenoid cartilage seen during post sale, endoscopic examination warrants notification to the purchaser and sales company. Medical therapy of affected horses should be considered and follow-up endoscopic examination performed to determine if the lesion has healed.

Resolución quirúrgica de la laringomalacia / Surgical resolution of laryngomalacia

Se presenta un caso de laringomalacia severa, con compromiso respiratorio importante, que llevaba al paciente a reiteradas hospitalizaciones, requiriendo incluso intubación. Se decide dar una solución quirúrgica a su patología, evolucionando de manera satisfactoria, con exámenes endoscópicos que demostraron su mejoría en forma inmediata. Se hizo, además una revisión del tema, sus causas, formas de presentación, diagnóstico y resolución quirúrgica de esta patología

Management of congenital laryngeal malformations.

Congenital malformations of the larynx are relatively rare but may be life-threatening. The most common causes include laryngomalacia, vocal cord paralysis, and subglottic stenosis. The last 20 years has seen major advances in the field of surgical correction of such anomalies also serving to reduce the number of tracheotomies in children and the inherent dangers they pose. Success rates for the most popular surgical procedures have been favorable. These include supraglottoplasty for cases of severe laryngomalacia, in which relief of respiratory symptoms has been shown to occur in excess of 80% of cases. Complication rate is low, although postoperative death has been reported. Failure usually occurs in patients with concomitant airway abnormalities including pharyngomalacia. Vocal cord lateralization for vocal cord paralysis with airway compromise is achieved by means of arytenoidopexy or arytenoidectomy, using the lateral approach. Arytenoidectomy also can be performed using laryngofissure or endoscopic laser excision. Subglottic stenosis is the 3rd most common congenital anomaly. Anterior or multiple cricoid splitting with cartilage graft interpositioning is usually performed. The success rates for these procedures has been shown to be approximately 90%.

Stridor in the neonate and infant. Implications for the paediatric anaesthetist. Prospective description of 155 patients with congenital and acquired stridor in early infancy.

One hundred-and-fifty-five neonates and infants up to the sixth month of postnatal age were investigated to reveal the cause of clinically relevant stridor. In 100 patients congenital stridor was found, in 55 children the stridor was considered to be acquired. A curled, soft epiglottis, almost synonymously used with the diagnosis of congenital stridor, was found in 7% only, indicating different methods of investigation and different selection of patients compared to previous years. In acquired stridor the majority of infants showed laryngeal and tracheal trauma, mostly due to the use of too large tracheal tubes.

Ariepiglotoplastia em laringomalácia severa / Aryepigloplasty in severe laryngomalacia

Laringomalácia é a mais comum causa de estridor congênito. Na maioria, os casos säo leves e näo requerem intervençäo cirúrgica. Entretanto, em aproximadamente 10 por cento das crianças, a condiçäo representa risco de vida. O tratamento padräo para estes pacientes tem sido realizar traqueotomia. Relatos recentes têm mostrado resultados encorajadores após cirurgia endoscópica nas estruturas supraglóticas. Relatamos uma série de 15 pacientes nos quais a traqueotomia foi evitada pela realizaçäo de ariepiglotoplastia. Foi observada melhora dramática após a cirurgia, em relaçäo à obstruçäo respiratória, dificuldade de alimentaçäo e alteraçäo do crescimento. A partir destes casos, foi implantada a ariepiglotoplastia como conduta nos Serviços de Otorrinolaringologia da UFU e FMSTRP

Interarytenoid notch height relative to the vocal folds. Pilot study.

We measured interarytenoid notch height (IANH) in 20 young children who required direct laryngoscopy under general anesthesia. By means of a specifically designed instrument, we found that the average IANH approximated 3 mm. Laryngeal incompetence on swallowing or in the presence of gastroesophageal reflux is associated with a low IANH (p < .0001). Therefore, IANH may be a measure of relative laryngeal incompetence.

Site of upper airway obstruction in infants following an acute life-threatening event.

Twenty-five patients were screened following an acute life-threatening event for the presence of obstructive and mixed apnea. Simultaneous cardiorespiratory monitoring with fiberoptic laryngoscopy was performed to identify the site of upper airway obstruction during these episodes. In 3 of these subjects, who had been born prematurely, obstruction was observed at the laryngeal level, with the arytenoid masses and aryepiglottic folds closing over across the vocal cords. Such closure was also observed during periodic breathing, which was found to be prominent in 4 of the infants studied. The possible role of laryngeal reflexes as a mechanism for these events is discussed.

Management of arytenoid chondropathy and failed laryngoplasty in horses: 75 cases (1979-1985).

By use of endoscopy, 75 horses with respiratory noise and/or exercise intolerance were determined to have structural arytenoid cartilage abnormalities (60 primary, 11 after previous laryngeal surgery), or failed left laryngoplasty (4 horses) for laryngeal hemiplegia in which the arytenoid cartilage still appeared normal. Eighty-eight percent of the horses were either Thoroughbred (54 horses; 72%) or Standardbred (12 horses; 16%) racehorses; only 9 horses (12%) had occupations not related to racing. Seventy-six percent of the racehorses were 2 to 4 years old; all non-racehorses were greater than 4 years old. The male:female ratio was approximately 2:1. Of the horses with cartilage abnormalities, 28 had left-sided involvement, 22 had right-sided involvement, and 21 had bilateral involvement. Sixty-two arytenoidectomies were performed, 58 for cartilage abnormalities (22 left, 19 right, 17 bilateral), and 4 for failed left laryngoplasties. Overall, 45% of the Thoroughbred racehorses that returned to racing after arytenoidectomy raced successfully (50% left, 75% right, 22% bilateral); only 20% of the Standardbreds were able to race. Seventy-five percent of non-racehorses were able to return to their previous use. Many horses were retired intentionally after surgery.

Congenital laryngeal stridor secondary to flaccid epiglottis, anomalous accessory cartilages and redundant aryepiglottic folds.

Most laryngeal anomalies are supraglottic and laryngomalacia is the most common. Cysts, bifid epiglottis and absence of the epiglottis are uncommon. An 18-year-old Caucasian man had long-standing stridor caused by anomalous supraglottic structures: a small floppy epiglottis, enlarged accessory cartilages and redundant aryepiglottic folds. These structures were excised and the airway was improved. The ventral portions of the fourth arches become the aryepiglottic folds and lateral segments of the epiglottis. A disturbance in this portion of the fourth arch may explain the anomaly. The cartilaginous contributions to the epiglottis were possibly isolated as accessory cartilages. Epiglottic anomalies may be associated with other anomalies, especially the digits of the hand. This patient had a short lingual frenulum and mild macroglossia.