A Large Cohort Analysis of Epiglottic Phenotypes and Pharyngeal Residue.

OBJECTIVE: To describe the phenotypic characteristics of the epiglottis at rest and their impact on vallecular residue. METHODS: Videofluoroscopic studies (VFSS) were pooled from 2 Laryngology practices, and Image J was used to measure epiglottic anatomic features at rest. Studies were rated by the MBSImp and presence of vallecular residue following swallow of thin and puree boluses. A conditional inference tree analysis was performed to isolate which epiglottic parameters were risk factors for presence of vallecular reside followed by logistic regression. RESULTS: The majority of patients had a normal shaped epiglottis, followed by omega shape. The mean angle of the epiglottis from the hyoid was approximately 90°. Only abnormal epiglottic movement was associated with increased risk of residue for thin boluses (OR 35.09, CI 10.93-158.66, P < .001). However, in those with normal epiglottic movement, age >70 years old was associated with increased risk of residue (OR 3.98, CI 1.73-9.23, P = .001). For puree boluses, a normal or omega shaped epiglottis was associated with residue (OR 5.19, CI 2.41-11.51, P < .001), and this relationship was further modulated by increased distance of the epiglottic tip from the posterior pharyngeal wall. No other anatomic features of the resting epiglottis were associated with residue. Comorbidities potentially affecting swallow were infrequent in the cohort and were not associated with residue. CONCLUSION: Abnormal epiglottic movement is associated with aspiration, and in this study we find that abnormal epiglottic movement increases the risk of vallecular residue and that older age is a risk factor for residue. The resting properties of the epiglottis do not appear to be associated with abnormal epiglottic movement or residue.

Effectiveness of ultrasonic measurement for the hyomental distance and distance from skin to epiglottis in predicting difficult laryngoscopy in children.

OBJECTIVES: Studies have shown that some ultrasonic indicators can predict difficult airways in adults to an extent. However, whether ultrasonic parameters can be used to predict difficult airways in children is unclear. This study investigated the predictive value of several ultrasonic indices for difficult laryngoscopy (DL) in children. METHODS: Pediatric patients aged 5 to 12 years who underwent endotracheal intubation under general anesthesia were enrolled. The hyomental distance in the extended position (HMDE), tongue thickness, midsagittal tongue cross-sectional area, tongue width, and distance from skin to epiglottis (DSE) were measured by ultrasound before anesthesia. The study end point was DL. The receiver operating characteristic curve was used to evaluate the predictive value of each parameter. RESULTS: Three hundred and ten children were included in the final analysis, and fifteen (4.8%) children had DL. The shortened HMDE assessed by ultrasound could help identify children aged 5 to 12 years with DL (5-8 years: area under the curve (AUC) 0.74, sensitivity 0.88, specificity 0.60; 9-12 years: AUC 0.72, sensitivity 0.71, specificity 0.83). An increased DSE could help identify children aged 5 to 8 years with DL (AUC 0.76, sensitivity 0.88, specificity 0.69). CONCLUSIONS: Ultrasonic measurement of the HMDE can be used to predict DL in children aged 5 to 12 years. The DSE measured by ultrasound can be used to predict DL in children aged 5 to 8 years. CLINICAL RELEVANCE STATEMENT: The hyomental distance and the distance from skin to epiglottis measured by ultrasound can be used to predict difficult laryngoscopy in children, which can help reduce serious complications caused by unanticipated difficult airways in children during anesthesia. KEY POINTS: • Ultrasonic measurement of the hyomental distance in the extended position may be an effective predictor of difficult laryngoscopy in children aged 5 to 12 years. • The distance from skin to epiglottis measured by ultrasound can be used to predict difficult laryngoscopy in children aged 5 to 8 years. • Preoperative airway assessment using ultrasound can be effectively applied in children and has a great application prospect.

Predicting difficult laryngoscopy in morbidly obese Thai patients by ultrasound measurement of distance from skin to epiglottis: a prospective observational study.

BACKGROUND: In morbidly obese patients, airway management is challenging since the incidence of difficult intubation is three times than those with a BMI within the healthy range. Standard preoperative airway evaluation may help to predict difficult laryngoscopy. Recent studies have used ultrasonography-measured distance from skin to epiglottis and pretracheal soft tissue at the level of vocal cords, and cut-off points of 27.5 mm and 28 mm respectively have been proposed to predict difficult laryngoscopy. The purpose of this study is to evaluate ultrasonography-measured distance from skin to epiglottis for predicting difficult laryngoscopy in morbidly obese Thai patients. METHODS: This prospective observational study was approved by the Ethics Committee of the Faculty of Medicine, Prince of Songkla University. Data were collected from January 2018 to August 2020. Eighty-eight morbidly obese patients (BMI ≥ 35 kg/m2) requiring general anesthesia with endotracheal intubation for elective surgery were enrolled in the Songklanagarind Hospital. Preoperatively, anesthesiologists or nurse anesthetists who were not involved with intubation evaluated and recorded measurements (body mass index, neck circumference, inter incisor distance, sternomental distance, thyromental distance, modified Mallampati scoring, upper lip bite test, and distance from skin to epiglottis by ultrasound. The laryngoscopic view was graded on the Cormack and Lehane scale. RESULTS: Mean BMI of the eighty-eight patients was 45.3 ± 7.6 kg/m2. The incidence of difficult laryngoscopy was 14.8%. Univariate analysis for difficult laryngoscopy indicated differences in thyromental distance, sternomental distance and the distance from skin to epiglottis by ultrasonography. The median (IQR) of thyromental distance in difficult laryngoscopy was 6.5 (6.3, 8.0) cm compared with 7.5(7.0, 8.0) cm in easy laryngoscopy (p-value 0.03). The median (IQR) of sternomental distance in difficult laryngoscopy was 16.8 (15.2, 18.0) cm compared with 16.0 (14.5, 16.0) cm in easy laryngoscopy (p-value 0.05). The mean distance from skin to epiglottis was 12.2 ± 3.3 mm Mean of distance from skin to epiglottis in difficult laryngoscopy was 12.5 ± 3.3 mm compared with 10.6 ± 2.9 mm in easy laryngoscopy (p-value 0.05). Multivariate logistic regression indicated the following factors associated with difficult laryngoscopy: age more than 43 years (A), thyromental distance more than 68 mm(B) and the distance from skin to epiglottis more than 13 mm(C). The scores to predict difficult laryngoscopy was calculated as 8A + 7B + 6C based on the data from our study. One point is given for A if age was more than 43 years old, 1 point is given for B if thyromental distance was less than 6.8 cm and 1 point is given for C if the distance from skin to epiglottis by ultrasonography was more than 13.0 cm. The maximum predicting score is 21, which indicates a probability of difficult laryngoscopy among our patients of 36.36%, odds 0.57, likelihood ratio 3.29 and area under the ROC curve of 0.77, indicative of a good predictive score. CONCLUSIONS: Age, thyromental distance and ultrasonography for the distance from skin to epiglottis can predict difficult laryngoscopy among obese Thai patients. The predictive score indicates the probability of difficult laryngoscopy.

A Retrospective Case Series of Anesthetic Patients With Epiglottic Cysts.

Previously undiagnosed or asymptomatic epiglottic cysts may be coincidentally detected during intubation. This retrospective case series identified undiagnosed epiglottic cysts that were discovered during intubation in 4 patients who underwent oral surgery under general anesthesia at our hospital during a 6-year period. Including 2 additional cases, 1 previously diagnosed and 1 detected during preoperative imaging, epiglottic cysts were observed in 6 of 1112 cases (0.54%) total. Among the undiagnosed epiglottic cyst cases, mild dyspnea on effort or snoring was reported in 2 patients, but all others were asymptomatic. Upon discovering previously undiagnosed epiglottic cysts during intubation, it is essential to proceed cautiously, remain alert for potential airway management difficulties, and avoid injuring or rupturing the cysts. In addition, any available preoperative imaging should be reviewed as information pertinent to the airway and any abnormalities may be useful. This report discusses the anesthetic care of 6 patients with epiglottic cysts that were previously known or initially discovered during intubation.

Anterior neck soft tissue measurements on computed tomography to predict difficult laryngoscopy: a retrospective study.

Predicting difficult laryngoscopy is an essential component of the airway management. We aimed to evaluate the use of anterior neck soft tissue measurements on computed tomography for predicting difficult laryngoscopy and to present a clear measurement protocol. In this retrospective study, 281 adult patients whose tracheas were intubated using a direct laryngoscope for thyroidectomy were enrolled. On computed tomography, the distances from the midpoint of the thyrohyoid membrane to the closest concave point of the vallecular (membrane-to-vallecula distance; dMV), and to the most distant point of the epiglottis (membrane-to-epiglottis distance; dME) were measured, respectively. The extended distances straight to the skin anterior from the dMV and dME were called the skin-to-vallecula distance (dSV) and skin-to-epiglottis distance (dSE), respectively. Difficult laryngoscopy was defined by a Cormack-Lehane grade of > 2. Difficult laryngoscopy occurred in 40 (14%) cases. Among four indices, the dMV showed the highest prediction ability for difficult laryngoscopy with an area under the receiver operating characteristic curve of 0.884 (95% confidence interval 0.841-0.919, P < 0.001). The optimal dMV cut-off value for predicting difficult laryngoscopy was 2.33 cm (sensitivity 75.0%; specificity 93.8%). The current study provides novel evidence that increased dMV is a potential predictive indicator of difficult laryngoscopy.

Diagnosis of Retrolingual Obstruction during Drug-Induced Sleep Endoscopy versus Polysomnography with Nasopharyngeal Tube in Patients with Obstructive Sleep Apnea.

OBJECTIVE: To compare the retrolingual obstruction during drug-induced sleep endoscopy (DISE) with the retrolingual obstruction during polysomnography with nasopharyngeal tube (NPT-PSG). METHODS: A cross-sectional study of 77 consecutive patients with moderate and severe obstructive sleep apnea (OSA) was conducted. After 15 patients were excluded from the study for not completing DISE or NPT-PSG successfully, 62 patients were included in this study. Retrolingual sites of obstruction grade 2 determined by DISE according to the VOTE (velum, oropharynx lateral wall, tongue base, and epiglottis) classification were considered as retrolingual obstruction, while apnea-hypopnea index (AHI) ≥ 15 events/hour determined by NPT-PSG was considered as retrolingual obstruction. The extent of agreement between DISE and NPT-PSG findings was evaluated using unweighted Cohen's kappa test. RESULTS: The 62 study participants (11 moderate OSA, 51 severe OSA) had a mean (SD) age of 39.8 (9.9) years, and 58 (94%) were men. No statistically significant differences between included and excluded patients were observed in patient characteristics. The extent of agreement in retrolingual obstruction between DISE and NPT-PSG was 80.6% (Cohen k = 0.612; 95% CI, 0.415-0.807). CONCLUSION: Retrolingual obstruction requiring treatment showed good agreement between DISE and NPT-PSG, suggesting that NPT-PSG may also be a reliable method to assess the retrolingual obstruction.

Prevalence of calcified epiglottis in postmortem computed tomography. Is there a correlation to failed endotracheal intubation?

OBJECTIVES: Calcification of the epiglottis is a normal physiological degenerative process, although it can also be a consequence of infection or trauma. There are three possible forensically relevant consequences from epiglottic calcification: misinterpretation as foreign bodies, dysphagia as a major contributing factor to aspiration, and association with difficult intubation or a misplaced ventilation tube. It is the aim of this study (I) to inquire about the prevalence of epiglottic calcification in postmortem CT in general and (II) to investigate whether calcification of the epiglottis is linked to a higher incidence of failed endotracheal intubation. METHODS: We retrospectively analysed 2930 consecutive cases in postmortem CT at the Institute of Forensic Medicine. RESULTS: The prevalence of epiglottic calcification was 4.1%. Higher age and male sex are associated with an increased risk of epiglottic calcification. There was no calcification of the epiglottis in the cases with misplacement of the ventilation tube in the esophagus. CONCLUSIONS: To verify the result of our study, that is, the calcification of the epiglottis is not linked to a higher incidence of failed endotracheal intubation, it might be reasonable to repeat this study with a more representative study population. The high interindividual variations of calcified epiglottis could be used for identification.

Epiglottic aplasia in an infant with Joubert syndrome.

Congenital aplasia of the epiglottis is a rare condition with variable presentation ranging from respiratory distress requiring surgical airway to an asymptomatic finding. Epiglottic aplasia is presumed to be caused by arrest of development of laryngeal structures and is most commonly associated with syndromic conditions, though isolated episodes of aplasia of the epiglottis do exist. In this report, we present a term infant with multiple congenital anomalies who was noted to have a hoarse cry prompting laryngoscopy. This showed complete absence of the epiglottis. Subsequent genetic testing showed mutations in the CPLANE1 gene that is associated with Joubert syndrome. Our patient was able to be discharged home on a thickened formula diet and is eating and gaining weight appropriately. Here, we present a review of the currently available literature of other cases of congenital epiglottic aplasia or hypoplasia discussing the presentation, management and outcomes in these cases.

Partial laryngectomy and reconstruction with rotation of the epiglottis in the treatment of a rare laryngeal schwannoma: a case report.

BACKGROUND: Neurogenic tumors of the larynx are rare, with few cases having been reported in the literature. Schwannomas are responsible for 0.1% of all benign tumors of the larynx. They arise in the sheaths of the peripheral, autonomic, and cranial nerves. The objective of this report is to describe a case of a bulky laryngeal schwannoma, the surgical procedure for its removal, and the long-term patient follow-up. CASE PRESENTATION: A 19-year-old Brazilian woman presented to our institution with a complaint of progressive dyspnea over the preceding year, as well as dysphonia, dysphagia for solids, and globus pharyngeus. Direct rigid laryngoscopy showed a supraglottic tumor obstructing approximately 90% of the larynx. With the symptoms progressing to severe dyspnea, an emergency tracheostomy was performed. After infusion of intravenous contrast, magnetic resonance imaging revealed a mass lesion with intense, heterogeneous contrast enhancement along the posterior wall of the hypopharynx, blocking all of the lumen and measuring 2.8 cm and 2.2 cm at its largest diameters. The image suggested a neoplastic lesion. The patient underwent open surgery for tumor resection. Her postsurgical recovery was uncomplicated. Histopathology and immunohistochemistry revealed the tumor to be a laryngeal schwannoma. CONCLUSION: The definitive diagnosis of laryngeal lesions can be difficult, and histopathology plays a pivotal role. Laryngeal schwannomas are rare; however, tumors can become large and may ultimately lead to airway obstruction.

Epiglottitis. / Epiglottitt.

BACKGROUND: Acute epiglottitis in adults is a rare, potentially life-threatening condition caused by a bacterial infection in the epiglottis. Typical symptoms are fever, sore throat, and respiratory distress caused by upper airway obstruction. Proper treatment is needed for a good outcome. CASE PRESENTATION: We here present a 54-year-old female patient with acute epiglottitis. Her airway was secured by endotracheal intubation and she received antimicrobial therapy. She developed an abscess around the epiglottis that needed surgical drainage and tracheotomy. However, she fully recovered after nine days in hospital. INTERPRETATION: Acute epiglottitis in adults is a potentially life-threatening condition. The prognosis is good with proper treatment including selective airway intervention, antimicrobial therapy, and close monitoring.

Robot-assisted epiglottopexy as a method for managing adult obstructive sleep apnea.

INTRODUCTION: Patients who do not tolerate continuous positive airway pressure (CPAP) for treatment of obstructive sleep apnea (OSA) often seek surgical management. A variety of procedures exist to address the nasal passages, oropharynx, hypopharynx, and larynx. Diagnostic studies including drug-induced sleep endoscopy (DISE) are helpful in identifying areas of obstruction. One potential site of obstruction is at the level of the epiglottis. We describe the use of robotic technology to assist with epiglottopexy to manage epiglottic retroflexion as a cause of two patients' OSA. This is the first reported robot-assisted epiglottopexy in the adult otolaryngology literature. METHODS: This is a case series of two patients with OSA who demonstrated epiglottis collapse into the airway during DISE. They were evaluated by polysomnographic testing (PSG), Epworth Sleepiness Scale (ESS), and physical exam. Given their epiglottic collapse seen on DISE, they underwent robot-assisted epiglottopexy. RESULTS: Both patients had moderate to severe OSA preoperatively. They successfully underwent robot-assisted epiglottopexy as a surgical intervention. They tolerated the procedure, and there have been no complications. Each reported improved symptoms, with patient one showing a decrease in total AHI and a substantial decrease in oxygen desaturations at night. The second patient reported a significant decrease in AHI and ESS. CONCLUSION: There are many options for surgical intervention in patients with OSA. Epiglottopexy is one method for addressing collapse of the epiglottis and can be achieved successfully through robot-assisted epiglottopexy in adult patients with OSA. LEVEL OF EVIDENCE: IV.

Ramsay Hunt syndrome affecting the vagus nerve with epiglottic ulcers as the first manifestation: a case report.

Ramsay Hunt syndrome involving the vagus nerve is very rare. We herein describe a 53-year-old man who developed severe pharyngeal pain after alcohol intoxication. Antibiotic treatment was ineffective. Laryngoscopy showed an ulcer on the right side of the epiglottis. As the condition progressed, the patient developed hoarseness. He then gradually developed multiple herpes lesions on the right side of the head, face, and neck along with right peripheral facial paralysis. Corticosteroid, analgesic, antiviral, and nutritional nerve therapy resulted in disappearance of the herpes lesions, epiglottis ulcer, pharyngeal pain, and right head and face pain. The facial paralysis slightly improved, but the hoarseness did not improve. The patient was discharged with an unsatisfactory outcome, and he attempted treatment with acupuncture. After 6 months, the right facial paralysis and hoarseness disappeared. Our case emphasizes the importance of early diagnosis and treatment of atypical Ramsay Hunt syndrome as well as timely communication, enhancement of trust, and reduction of disputes between doctors and patients.

Three-dimensional finite element modeling for evaluation of laryngomalacia severity in infants and children.

This study was performed to investigate the feasibility of using a three-dimensional (3D) finite element model for laryngomalacia severity assessment. We analyzed laryngeal computed tomography images of seven children with laryngomalacia using Mimics software. The gray threshold of different tissues was distinguishable, and a 3D visualization model and finite element model were constructed. The laryngeal structure parameters were defined. The peak von Mises stress (PVMS) value was obtained through laryngeal mechanical analysis. The PVMS values of the laryngeal soft tissue and cartilage scaffolds were independently correlated with disease severity. After stress loading the model, the relationship between laryngomalacia severity and the PVMS value was apparent. However, the PVMS value of laryngeal soft tissue was not correlated with laryngomalacia severity. This study established the efficacy of a finite element model to illustrate the morphological features of the laryngeal cavity in infants with laryngomalacia. However, further study is required before widespread application of 3D finite element modeling of laryngomalacia. PVMS values of the laryngeal cartilage scaffold might be useful for assessment of laryngomalacia severity. These findings support the notion that structural abnormalities of the laryngeal cartilage may manifest as quantifiable changes in stress variants of the supraglottic larynx.

Automatic vocal tract landmark localization from midsagittal MRI data.

The various speech sounds of a language are obtained by varying the shape and position of the articulators surrounding the vocal tract. Analyzing their variations is crucial for understanding speech production, diagnosing speech disorders and planning therapy. Identifying key anatomical landmarks of these structures on medical images is a pre-requisite for any quantitative analysis and the rising amount of data generated in the field calls for an automatic solution. The challenge lies in the high inter- and intra-speaker variability, the mutual interaction between the articulators and the moderate quality of the images. This study addresses this issue for the first time and tackles it by means of Deep Learning. It proposes a dedicated network architecture named Flat-net and its performance are evaluated and compared with eleven state-of-the-art methods from the literature. The dataset contains midsagittal anatomical Magnetic Resonance Images for 9 speakers sustaining 62 articulations with 21 annotated anatomical landmarks per image. Results show that the Flat-net approach outperforms the former methods, leading to an overall Root Mean Square Error of 3.6 pixels/0.36 cm obtained in a leave-one-out procedure over the speakers. The implementation codes are also shared publicly on GitHub.