Impact of balloon laryngoplasty on management of acute subglottic stenosis.

PURPOSE: To assess the impact of balloon laryngoplasty on clinical and surgical outcomes in pediatric patients with acute subglottic stenosis. METHODS: Two case series were included and compared. The first group included patients treated initially either with tracheostomy (if severe symptoms) or with close follow-up (if mild symptoms). Those children underwent re-evaluation and specific treatment of their stenosis with laser incisions or open surgeries some weeks later. The other group included children treated initially with balloon laryngoplasty, reflecting a shift in surgical practice after 2009. Data as success of the procedure, mean hospital stay, mean pediatric intensive care unit (PICU) stay, post-procedure fever, need of antibiotics, procedure-related complications, and deaths were assessed and compared between both cohorts. RESULTS: The sample comprised 38 pediatric patients aged 0-5 years. Fifteen children were treated before 2009, of who 10 (66.7%) required tracheostomy soon after the diagnosis. Ultimately, 13 (86.6%) underwent laryngotracheal reconstruction. Twenty-three children were treated after 2009 and the success rate in these patients treated primarily with balloon laryngoplasty was 82.6%. Of these, only 3 (13%) required tracheostomy and 1 (4.3%) required further open laryngotracheal reconstruction. Patients treated by balloon laryngoplasty underwent fewer procedures under general anesthesia and had a lower burden of treatment-related morbidity, as denoted by shorter PICU stay, less antibiotic use, earlier postoperative resumption of oral feeding, and a lower incidence of postoperative complications and fever. CONCLUSION: When used for management of acute laryngeal stenosis, balloon laryngoplasty is associated with a high success rate, presenting lower morbidity than open surgery.

Association of endotracheal tube repositioning and acute laryngeal lesions during mechanical ventilation in children.

The objective of this study is to determine the incidence of post-extubation acute laryngeal lesions in a pediatric intensive care unit (PICU) and potential risk factors. Children, aged 28 days to 5 years, admitted to the PICU who required endotracheal intubation for at least 24 h were enrolled. Exclusion criteria were a previous intubation, history of laryngeal disease, current or past tracheostomy, the presence of craniofacial malformations and patients considered on palliative care. All patients underwent flexible fiber-optic laryngoscopy (FFL) not later than 8 h after extubation. A blinded researcher identified and classified laryngeal lesions based on recorded media. 231 children were enrolled between November 2005 and December 2015. At FFL examination, 102 children (44.15%) presented moderate to severe laryngeal lesions. On a multivariable analysis, we found that for each additional day with repositioning of the endotracheal tube, there was an increase of 7.3% (RR 95% CI 1.012-1.137; P = 0.018) on the baseline risk of developing moderate to severe acute laryngeal lesions. Furthermore, for each additional dose of sedation per day of intubation, there was also an increase of 3.5% on the same baseline risk (RR 95% CI 1.001-1.070; P = 0.041). The amount of tube repositioning episodes and the need for extra doses of sedation (as a proxy for possible agitation) were found to be associated with acute laryngeal lesions. Adequate sedation and minimized tube repositioning should be pursued to possibly prevent the development of post-extubation airway compromise.

Maxillary Hypoplasia: Differential Diagnosis of Nasal Obstruction in Infants.

Maxillary hypoplasia (MH) is a rare cause of respiratory dysfunction in infants and may occur in association with genetic abnormalities or as an isolated condition. It is included in the differential diagnosis of congenital nasal obstruction. This paper seeks to report a case series of infants with MH, discuss methods for its diagnosis, and compare computed tomography (CT) measurements of nasal cavities of infants with MH and without craniomaxillofacial abnormalities. The therapeutic approach in each patient is also described. All infants with MH admitted to a tertiary hospital between 2012 and 2015 were included. Baseline nasal endoscopy was performed at bedside. The width of the infants' nasal cavities was measured by a radiologist with experience in CT scanning of facial bones. Control patients were infants of matched sex and similar age who underwent head CT scanning for various reasons. Overall, 8 infants with MH and 8 controls were assessed. All nasal cavity dimensions of infants with MH were significantly smaller than those of control subjects. The authors conclude that the diagnosis of MH should be considered in infants with nasal obstruction and nasal cavity narrowing at nasal endoscopy.

High microbiome variability in pediatric tracheostomy cannulas in patients with similar clinical characteristics.

OBJECTIVES: To evaluate the bacterial microbiome found in tracheostomy cannulas of a group of children diagnosed with glossoptosis secondary to Robin Sequence (RS), and its clinical implications. METHODS: Pediatric patients were enrolled in the study at the time of the cannula change in the hospital. During this procedure, the removed cannula was collected and stored for amplicon sequencing of 16s rRNA. DNA extraction was performed using DNeasy PowerBiofilm Kit (QIAGEN® ‒ Cat nº 24000-50) while sequencing was performed with the S5 (Ion S5™ System, Thermo Fisher Scientific), following Brazilian Microbiome Project (BMP) protocol. RESULTS: All 12 patients included in the study were using tracheostomy uncuffed cannulas of the same brand, had tracheostomy performed for over 1-year and had used the removed cannula for approximately 3-months. Most abundant genera found were Aggregatibacter, Pseudomonas, Haemophilus, Neisseria, Staphylococcus, Fusobacterium, Moraxella, Streptococcus, Alloiococcus, and Capnocytophaga. Individual microbiome of each individual was highly variable, not correlating to any particular clinical characteristic. CONCLUSION: The microbiome of tracheostomy cannulas is highly variable, even among patients with similar clinical characteristics, making it challenging to determine a standard for normality.

Sialendoscopy for Improvement of Salivary Flow in Patients with Sjögren Syndrome - Comparative Analysis of Intraglandular Washing Solutions.

Introduction Among the potential diseases that present altered salivary flow and activity is Sjögren syndrome. Sialendoscopy seems to be an important therapeutic option. Objective To compare the results obtained with sialendoscopy for improving salivary flow measured by scintigraphy in patients with primary Sjögren syndrome to those obtained with other intraglandular washing solutions. Methods Patients from our institution's rheumatology clinic diagnosed with primary Sjögren syndrome underwent parotid scintigraphy prior to the sialendoscopy procedure. During the sialendoscopy procedure, one of the parotid glands was randomized to receive a wash with saline while the other was washed with a corticosteroid solution. After 1 month, a new scintigraphy examination of the parotid glands was performed to observe the salivary flow for comparison. Results A total of 13 female patients with mean age of 53.38 years (range, 27-76 years) were included in this study. After sialendoscopy, 10 patients (76.92%) were observed to have improvement in salivary excretion with radiopharmaceutical during scintigraphy. When analyzing each gland that was treated separately (26 glands), after sialendoscopy, improvement was observed in 18 glands (69.23%), 8 treated with dexamethasone and 10 with saline solution in the wash. There was no improvement in 8 glands (30.77%). Conclusion This study demonstrates that sialendoscopy is as an important tool to improve salivary flow measured by scintigraphy in patients with primary Sjogren syndrome, increasing salivary excretion through dilation and consequent unblocking of the ducts. These data suggest that there is no statistically significant difference between intraductal washing solutions using saline or dexamethasone solution.

Accuracy of stridor-based diagnosis of post-intubation subglottic stenosis in pediatric patients.

OBJECTIVE: To assess the accuracy of stridor in comparison to endoscopic examination for diagnosis of pediatric post-intubation subglottic stenosis. METHOD: Children who required endotracheal intubation for >24h were included in this prospective cohort study. Children were monitored daily and underwent flexible fiberoptic laryngoscopy after extubation. Those with moderate-to-severe abnormalities underwent another examination 7-10 days later. If lesions persisted or symptoms developed, laryngoscopy under general anesthesia was performed. Patients were assessed daily for stridor after extubation. RESULTS: A total of 187 children were included. The incidence of post-extubation stridor was 44.38%. Stridor had a sensitivity of 77.78% (95% confidence interval [95% CI]: 51.9-92.6) and specificity of 59.18% (95% CI: 51.3-66.6) in detecting subglottic stenosis. The positive predictive value was 16.87% (95% CI: 9.8-27.1), and the negative predictive value was 96.15% (95% CI: 89.9-98.8). Stridor persisting longer than 72h or starting more than 72h post-extubation had a sensitivity of 66.67% (95% CI: 41.2-85.6), specificity of 89.1% (95% CI: 83.1-93.2), positive predictive value of 40.0% (95% CI: 23.2-59.3), and negative predictive value of 96.07% (95% CI: 91.3-98.4). The area under the receiver operating characteristic (ROC) curve was 0.78 (95% CI: 0.65-0.91). CONCLUSIONS: Absence of stridor was appropriate to rule out post-intubation subglottic stenosis. The specificity of this criterion improved when stridor persisted longer than 72h or started more than 72h post-extubation. Thus, endoscopy under general anesthesia can be used to confirm subglottic stenosis only in patients who develop or persist with stridor for more than 72h following extubation.

Diagnostic accuracy of current glossoptosis classification systems: A nested cohort cross-sectional study.

OBJECTIVES/HYPOTHESIS: To assess the performance of endoscopic grading systems of glossoptosis in identifying severe clinical manifestations in children with Robin sequence (RS). STUDY DESIGN: Nested cohort cross-sectional study. METHODS: All RS patients diagnosed at Hospital Clinics of Porto Alegre from October 2012 to June 2016 were enrolled in this cohort. Patients underwent sleep endoscopy and were classified according to Yellon (Y) and de Sousa et al. (S) scales. Symptom severity evaluation was performed as defined by Cole et al. The outcome of interest was Cole's clinical classification grade 3. RESULTS: Eighty patients were eligible for analysis. Sensitivity (Y: 56.2%, S: 28.1%, P < .001) and specificity (Y: 85.4%, S: 93.8%, P = .038) in identifying severe clinical symptoms patients (i.e., Cole grade 3) were statistically different between Y and S classifications. A low but significant overall correlation was observed for both Y (rho = 0.372, P < .001) and S (rho = 0.439, P < .001) classifications when compared with Cole classification. Diagnostic odds ratio (DOR) for Y (DOR: 7.53, 95% confidence interval [CI]: 4.15-10.90) and S (DOR: 5.87, 95% CI: 1.86-9.87) were equivalent (P = .92). Also, receiver operating characteristic curves area under the curve were not significantly different between them. The positive likelihood ratio was 3.86 (95% CI: 1.82-8.16) and 4.50 (95% CI: 1.32-15.36) for Y and S, respectively. CONCLUSIONS: Y and S grading systems showed a low sensitivity and moderate to high specificity in detecting patients with severe clinical manifestations. Correlation between Y/S and Cole et al. grading were also considered low. Development of a more discriminative anatomic grading system is still needed for this specific disorder. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:502-508, 2018.

Association of polysomnographic parameters with clinical symptoms severity grading in Robin sequence patients: a cohort nested cross-sectional study.

OBJECTIVES: To evaluate the association of polysomnographic parameters with clinical symptom severity in Robin sequence (RS) patients. METHODS: All patients diagnosed as presenting with RS at Hospital de Clínicas de Porto Alegre from October 2012 to June 2016 were enrolled. They were classified as isolated RS, RS-plus, and syndromic RS. Polysomnography (PSG) was performed, except for those patients in need of respiratory support. Symptom severity was evaluated as defined by the Cole et al. CLASSIFICATION: Ordinal OR (for the chance of increase in one grade on the clinical severity scale) and R2 (determination coefficient from ordinal logistic regression) were computed from data analysis. RESULTS: A total of 80 participants were enrolled in the study. Fifty-five of these were able to undergo polysomnography. Worsening of the studied PSG parameters was associated with increase in clinical severity grading, as follows: desaturation index (OR 1.27; 95% CI; 1.07-1.51; R2 = 19.8%; p = 0.006); apnea/hypopnea Index (OR 1.13; 95% CI; 1.01-1.26; R2 = 12.5%; p = 0.02); sleep mean oxygen saturation (OR 0.16; 95% CI; 0.05-0.52; R2 = 22.6%; p = 0.002); oxygen saturation nadir (OR 0.73; 95% CI; 0.56-0.96; R2 = 10.0%; p = 0.02); percentage of time with oxygen saturation <90% (OR 9.49; 95% CI; 1.63-55.31, R2 = 37.6%; p = 0.012); and percentage of time presenting with obstruction (OR 2.5; 95% CI; 1.31-4.76; R2 = 25.1%; p = 0.006). CONCLUSIONS: Polysomnography parameters were associated with severity of clinical manifestations in patients with RS. Oxyhemoglobin saturation-based parameters had surprisingly significant R2 values. Therefore, those parameters, which have traditionally been undervalued in other clinical settings, should also be assessed in the polysomnographic evaluation of RS patients.

Influence of dietary and physical activity restriction on pediatric adenotonsillectomy postoperative care in Brazil: a randomized clinical trial.

INTRODUCTION: Although culturally food and physical activity restriction are part of the routine postoperative care of many Brazilian surgeons, current evidences from other countries support no such recommendations. OBJECTIVE: To determine whether dietary and physical restriction effectively lead to a decrease on postoperative complications of adenotonsillectomy in children when compared to no restriction. METHODS: We have designed a randomized clinical trial comparing two intervention: no specific counseling on diet or activity (Group A), and restriction recommendations on diet and physical activities (Group B). Caregivers completed a questionnaire on observed pain, diet and activity patterns, and medications administered. Parameters were compared at the 3rd and at the 7th postoperative day between intervention groups. RESULTS: We have enrolled a total of 95 patients, 50 in Group A and 45 in Group B. Fourteen patients were lost to follow up. Eventually, 41 patients in group A and 40 in Group B were available for final analysis. Mean age in months (A=79.5; SD=33.9/B=81.1; SD=32.6) and sex (A=58% male; B=64.4% male) were equivalent between groups. Pain, evaluated through visual analog scale in the 3rd (A=2.0; IQR 1-6/B=4.5; IQR 2-6; p=0.18) and in the 7th (A=1.0; IQR 1.0-4.5/B=2.0; IQR 1.0-4.7; p=0.29) postoperative days, was not different between groups, as was the amount of analgesics administered. Dietary and physical activity patterns also showed no statistically significant differences between groups. CONCLUSION: Dietary and activity restriction after adenotonsillectomy does not seem to affect patients' recovery. Such information may impact considerably on the social aspects that involve a tonsillectomy, reducing the working days lost by parents and accelerating the return of children to school.

The effect of mandibular distraction osteogenesis on airway obstruction and polysomnographic parameters in children with Robin sequence.

INTRODUCTION: The optimal surgical technique for the management of patients with Robin Sequence (RS) has not been established. One of the most commonly used surgical techniques, mandibular distraction osteogenesis (MDO), is still controversial because of its potential risks and the lack of clear evidence of its efficacy. OBJECTIVES: To assess variations in airway patency, clinical symptoms, and polysomnographic parameters in children with RS who underwent MDO. METHODS: In this prospective cohort study, 38 patients with RS were evaluated before and after MDO. Symptom severity was classified using a grading scale for RS clinical manifestations. Patients underwent flexible fiberoptic laryngoscopy, and the images were classified by a blinded examiner using two validated grading scales for airway obstruction. Patients not requiring ventilatory support underwent a polysomnography. RESULTS: Patients' symptoms significantly improved after MDO, as shown by a decreased score in the grading scale for RS clinical manifestations (preoperative score of 2.20 vs. postoperative score of 0.81; P < 0.001). The two endoscopic grading scales also showed a statistically significant postoperative improvement in airway obstruction (first scale: preoperative score of 1.56 vs. postoperative score of 0.92; second scale: preoperative score of 2.19 vs. postoperative score of 1.16; P < 0.001 for both). Moreover, there was a statistically significant variation in the following polysomnographic parameters evaluated pre- and postoperatively: apnea-hypopnea index, total sleep time, oxygen desaturation nadir, and oxygen desaturation index (P < 0.05). CONCLUSIONS: MDO seems to be an effective surgical option for children, as shown by postoperative improvements in clinical symptoms, endoscopic grading scales, and polysomnographic parameters.

High microbiome variability in pediatric tracheostomy cannulas in patients with similar clinical characteristics

Abstract Objectives: To evaluate the bacterial microbiome found in tracheostomy cannulas of a group of children diagnosed with glossoptosis secondary to Robin Sequence (RS), and its clinical implications. Methods: Pediatric patients were enrolled in the study at the time of the cannula change in the hospital. During this procedure, the removed cannula was collected and stored for amplicon sequencing of 16s rRNA. DNA extraction was performed using DNeasy PowerBiofilm Kit (QIAGEN® - Cat nº 24000-50) while sequencing was performed with the S5 (Ion S5™ System, Thermo Fisher Scientific), following Brazilian Microbiome Project (BMP) protocol. Results: All 12 patients included in the study were using tracheostomy uncuffed cannulas of the same brand, had tracheostomy performed for over 1-year and had used the removed cannula for approximately 3-months. Most abundant genera found were Aggregatibacter, Pseudomonas, Haemophilus, Neisseria, Staphylococcus, Fusobacterium, Moraxella, Streptococcus, Alloiococcus, and Capnocytophaga. Individual microbiome of each individual was highly variable, not correlating to any particular clinical characteristic. Conclusion: The microbiome of tracheostomy cannulas is highly variable, even among patients with similar clinical characteristics, making it challenging to determine a standard for normality. © 2022 Associa¸c˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (https://creativecommons.org/licenses/by/4.0/).

Development and in vivo testing of a Nitinol tracheal stent.

This article describes the development of a Nitinol tracheal stent (HCPA NiTi-stent) and its application in a feline animal model. Straight-annealed, bright-polished Nitinol wire (55.8%Ni-44.2%Ti) was weaved around a 40-mm-long metal fixture with 8-mm diameter. The prototypes were submitted to different times of shape-setting heat treatment (530 degrees C), which resulted in stents of different colors and caused some variation in length and diameter. The prototypes were then submitted to compression testing, and the most resistant pieces, requiring the greatest force to achieve a 25% reduction in diameter and presenting the least variation in length and diameter (dark blue, 9 min of heat treatment), were submitted to fatigue testing. After that, only dark blue stents were manufactured and implanted in felines. No migration, tracheal stenosis, or any other type of damage were observed after 40 weeks. The integrity of the tracheal wall in contact with the stent was confirmed by macro and microscopic analyses. The development and in vivo testing of the HCPA NiTi-stent were successful.

Flexible fiber-optic laryngoscopy in the first hours after extubation for the evaluation of laryngeal lesions due to intubation in the pediatric intensive care unit.

OBJECTIVE: To evaluate the feasibility and safety of using fiber-optic laryngoscopy in the first hours after extubation for the early diagnosis of laryngeal lesions in infants and children in the pediatric intensive care unit and describe the findings of such approach. METHODS: Patients 0-4 years old who had undergone endotracheal intubation for longer than 24h were included in the study. Exclusion criteria were history of laryngeal symptoms, current intubation or tracheostomy, craniofacial malformations, or a poor prognosis according to the medical team responsible for the patient. Exams were performed in the pediatric intensive care unit in the first 8h after extubation; the patient was at the bedside and did not receive sedation. The fiber-optic laryngoscope was used to obtain images of the larynx. Minor complications were: saturation decrease not below 85% and rapid recovery, and minor nasal bleeding. Severe complications were: bradycardia and laryngospasm that required intervention. Images were evaluated by a blinded examiner, and findings were classified as mild and unspecific (edema and hyperemia), or specific, such as laryngomalacia and glottic granulation and subglottic ulceration and granulation. Results were expressed as means and standard deviations when the variable had a normal distribution, and as median and interquartile ranges for asymmetric data. RESULTS: Forty-one patients, mean age 2.7 months (interquartile range 1.5-6.1), were included in the study. Fiber-optic laryngoscopy was performed between 40 min and 8h after extubation, and mean time was 4.9h (standard deviation=2.4h). Mean exam duration was 4.16 min (2.41-7.12 min; standard deviation=1 min). One patient (2.4%) had mild desaturation, a minor complication. No other complications were found. Thirty-five patients were available to 6-month follow-up and subglottic stenosis was found in 11.4%. CONCLUSIONS: Fiber-optic laryngoscopy may be safely performed in the first hours after extubation, with few minor complications. It does not take long, but provides accurate information about the conditions of the supraglottic and glottic larynx. The subglottic region can also be visualized in most patients. This easily performed exam seems to be useful for the diagnosis of pediatric patients with acute laryngeal lesions due to intubation.

Tracheostomy in children: a ten-year experience from a tertiary center in southern Brazil.

INTRODUCTION: Children may require tracheostomy due to many different health conditions. Over the last 40 years, indications of tracheostomy have endorsed substantial modifications. OBJECTIVE: To evaluate pediatric patients warranted tracheostomy at our Hospital, in regard to their indications, associated comorbidities, complications and decannulation rates. METHODS: Retrospective study concerning patients under 18 years of age undergoing tracheostomy in a tertiary health care center, from January 2006 to November 2015. RESULTS: 123 children required a tracheostomy after ENT evaluation during the study period. A proportion of 63% was male, and 56% was under one year of age. Glossoptosis was the most common indication (30%), followed by subglottic stenosis (16%) and pharyngomalacia (11%). The mortality rate was 31%. By the end of this review, 35 children (28.4%) had been decannulated, and the fewer the number of comorbidities, the greater the decannulation rate (0.77±0.84 vs. 1.7±1.00 comorbidities; p<0.001). CONCLUSION: Tracheostomy in children is a relatively frequent procedure at our hospital. The most common indications are glossoptosis and subglottic stenosis. A high mortality rate was found, potentially substantiated by the high number of critical care patients with chronic neurological conditions in this cohort. Our decannulation rate is slightly below other series, probably because of the greater amount of patients with comorbidities.

Accuracy of clinical swallowing evaluation for diagnosis of dysphagia in children with laryngomalacia or glossoptosis.

OBJECTIVE: To investigate the accuracy of clinical evaluation of swallowing in a sample of children with laryngomalacia or glossoptosis and describe the prevalence of dysphagia in each of these diseases, as well as characterize the swallow response to speech and language therapy interventions. STUDY DESIGN: Children aged 1 month to 11 years receiving care at the Department of Otolaryngology, Hospital de Clínicas de Porto Alegre, Brazil, were evaluated in a cross-sectional design. Evaluation of swallowing was performed at two time points by two blinded speech-language pathologists, one responsible for clinical evaluation and the other for videofluoroscopic study. The protocols employed were based on the instruments proposed by DeMatteo et al. (DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol 2005;47:149-157.). RESULTS: The study sample consisted of 29 patients: 10 patients with laryngomalacia and 19 patients with glossoptosis. The sensitivity of clinical evaluation did not exceed 50% in any of the evaluations, but specificity reached 100% in some cases, using thickened liquids. The prevalence of dysphagia was 100%, and the use of thickened liquids significantly reduced tracheal aspiration. CONCLUSIONS: Dysphagia was highly prevalent in this sample. The sensitivity of clinical evaluation to detect laryngeal penetration and tracheal aspiration was low, as the majority of aspiration events were silent. The videofluoroscopic study is important in order to determine a safest method to feed the patient. Pediatr Pulmonol. 2017;52:41-47. © 2016 Wiley Periodicals, Inc.

Undersedation is a risk factor for the development of subglottic stenosis in intubated children.

OBJECTIVE: To analyze the level of sedation in intubated children as a risk factor for the development of subglottic stenosis. METHODS: All patients between 30 days and 5 years of age who required endotracheal intubation in the pediatric intensive care unit between 2013 and 2014 were included in this prospective study. They were monitored daily and COMFORT-B scores were obtained. Flexible fiber-optic laryngoscopy was performed within eight hours of extubation, and repeated seven to ten days later if the first examination showed moderate to severe laryngeal injuries. If these lesions persisted and/or if the child developed symptoms in the follow-up period, microlaryngoscopy under general anesthesia was performed to evaluate for subglottic stenosis. RESULTS: The study included 36 children. Incidence of subglottic stenosis was 11.1%. Children with subglottic stenosis had a higher percentage of COMFORT-B scores between 23 and 30 (undersedated) than those who did not develop subglottic stenosis (15.8% vs. 3.65%, p=0.004). CONCLUSION: Children who developed subglottic stenosis were less sedated than children who did not develop subglottic stenosis.

The role of flexible fiberoptic laryngoscopy in Robin Sequence: A systematic review.

OBJECTIVE: Systematically search literature for flexible fiberoptic laryngoscopy (FFL) use in Robin Sequence (RS) patients, in diverse clinical scenarios. DATA SOURCES: Pubmed, LILACS and SCIELO. REVIEW METHODS: Systematic review using a sensitive search strategy focused on RS patients and FFL. RESULTS: There were 48 full text articles included in this systematic review. No summary meta-analytic measurement could be calculated due to heterogeneity of interventions and outcomes. FFL approaches were grouped in five topics, as follows: Endoscopic classification: no evidence on superiority of awake over light sedation and correlation of grading scales with symptom severity. Airway abnormalities: high incidence of concomitant lesions besides glossoptosis. Swallowing evaluation: no validation against fluoroscopy (gold standard) yet. Intubation aid for mechanical ventilation: ultra-thin bronchoscopes improve success rates of intubation. Treatment outcome monitoring: no consensus on ideal parameters to be checked. CONCLUSION: Some applications have their roles already well established in the management of RS patients, like the evaluation of glossoptosis and associated lesions and as an intubation assistance tool, while others need to be the subject of further research, like the exact method of evaluation, its association with clinical manifestations, its role in swallowing investigation and as a postoperative success predictor.

Transsexual Voice Questionnaire for Male-to-female Brazilian Transsexual People.

OBJECTIVES: The aim of the study was to verify the answers to the transsexual voice questionnaire for male-to-female transsexual (TVQMtF) people given to individuals who participated in the Gender Identity Program (PROTIG) at the Hospital de Clínicas de Porto Alegre, Brazil, in relation to some of their demographic characteristics, visual-perceptual evaluations of the face, laryngeal prominence, and auditoryperceptual judgments of voice. METHODS: In this cross-sectional study, 47 transsexual women aged between 18 and 50 responded to the (TVQMtF). The demographic data and perceptual ratings were selected from the PROTIG database. RESULTS: Among all participants, 55.32% had completed secondary education, and 72.34% had not undergone a sex reassignment surgery; 4.2% of subjects did not use hormones, 23.40% had undergone speech therapy, the average number of years of experience in the female role was 13.98 years, and the participants had been definitively cross-dressing for 5-34 years. Most of the participants had low scores on the (TVQMtF), and significant differences in the total score were observed in accordance with age (higher scores were observed among those <30 years and ≥40 years old) and visual-perceptual evaluations of the face (higher scores were observed in the individual evaluated with masculine face). There were no significant correlations between the total score obtained by the participants and the other demographic variables. CONCLUSIONS: Although most of the participants had low scores on the (TVQMtF), some individuals were still experiencing distress due to being perceived as being of the opposite sex or were dissatisfied with their voices.

Laryngeal surgical treatment in transgender women: A systematic review and meta-analysis.

OBJECTIVE: To identify the effects of laryngeal surgical treatment in the voice of transgender women, especially on the fundamental frequency (f0). STUDY DESIGN: We performed a systematic review in PubMed and Scopus in July 2016, covering the period between 2005 and 2016. METHODS: Inclusion criteria were studies in English or Portuguese about the laryngeal surgical treatment in transgender women, featuring experimental design, title, year of publication, country of origin, journal of publication, participants, intervention, results. For the meta-analysis, only studies that had control group were selected. Exclusion criteria were articles that mentioned the use of surgical techniques but did not use the procedure in research, animal studies, studies of revision, and postmortem studies. RESULTS: Four hundred and twenty-three articles were identified in the initial search; 94 were selected for analysis by two referees, independently. After applying all the selection criteria, five studies remained in the meta-analysis. The surgical procedures that were identified included laryngoplasty with or without thyrohyoid approximation, Wendler glottoplasty, cricothyroid approximation, laser glottoplasty reduction and the vocal fold shortening and retrodisplacement of anterior commissure. There was no significant difference between the experimental group and the control group in relation to f0. CONCLUSION: No randomized clinical trials and prospective cohort studies are available, and a small number of retrospective cohort and case-control studies of surgical techniques reveal an increase in the f0. The evidence produced is not conclusive regarding which surgical technique would be better for vocal treatment of transgender women. LEVEL OF EVIDENCE: NA Laryngoscope, 127:2596-2603, 2017.

Glossoptosis.

Glossoptosis causes varying degrees of airway obstruction and feeding difficulties. It can occur as a consequence of micrognathia in Robin Sequence, but can also occur in children with hypotonia. Despite several attempts to classify severity in Robin Sequence patients, taking into account symptoms, presence of concomitant syndromes or malformations, and even endoscopic findings, there is still no general consensus. Furthermore, several management recommendations have been reported without an agreement about indications, efficacy, or risks of each treatment option. The present article provides an overview of clinical presentation, diagnosis, management, and prognosis of patients with glossoptosis.