Difficult Laryngeal Exposure Research Articles

Using Office-Based Zero-Degree Rigid Laryngoscopy to Predict Glottic Exposure in Microlaryngoscopy

OBJECTIVESPoor glottic exposure in microlaryngeal surgery can result in difficult instrumentation or incomplete surgery affecting surgical outcomes. Anticipating poor glottic exposure preoperatively allows surgeons to prepare adequately, ensuring successful surgery. This study aims to determine diagnostic utility of 4mm zero-degree rigid endoscopic laryngeal examination as a tool to predict glottic exposure in microlaryngoscopy. STUDY DESIGNCross-sectional observational study. METHODSThis is a cross-sectional study, conducted from 1st March 2022 to 30th November 2023 at the ENT department of a tertiary care hospital in North India. Total of 35 adult participants who underwent MLS were consecutively enrolled. Participants in whom the lesion was obscuring the anterior commissure and in whom gag reflex prevented complete 0-degree laryngeal examination were excluded from the study. All enrolled participants were evaluated preoperatively with a 4 mm rigid zero-degree laryngoscopic examination and the laryngoscore. The total score on the laryngoscore proforma was calculated and recorded. The visualized glottis on zero-degree laryngoscopy was graded as follows: Grade 1, anterior commissure and the entire glottic plane can be seen; Grade 2, glottis can be seen but not the anterior commissure; Grade 3, only the posterior half of the glottis can be seen; Grade 4, only the arytenoids can be seen. The glottic exposure on microlaryngoscopy was also assessed using the same grading system. Depending on the exposure of the anterior commissure, the cohort was divided into two groups: good laryngeal exposure and difficult laryngeal exposure. Receiver operating characteristic curve analysis was done to evaluate the predictive accuracy of 0-degree laryngoscopy and to compare it with laryngoscore. RESULTSA total of 35 adults participated in the study, of which 28 were men (80%) with median (range) age of 45(24-76) years. The area under the curve for 0-degree laryngoscopy and laryngoscore were 0.97 and 0.83 respectively. Optimal cutoff value (sensitivity, specificity) to identify difficult laryngeal exposure for 0-degree laryngoscopy and laryngoscore were 1.5 (93.3%,100%) and 4.5 (80%,85%) respectively. CONCLUSIONZero-degree laryngoscopy is an excellent predictor of glottic exposure on microlaryngoscopy. Its accuracy surpasses that of the laryngoscore in identifying an ideal candidate for microlaryngoscopy.

Predictors of Difficult Laryngeal Exposure in Suspension Laryngoscopy: A Systematic Review and Meta-Analysis.

Considerable research has been focused on independent predictors of difficult laryngeal exposure (DLE) during suspension laryngoscopy. However, previous studies have yielded inconsistent results and conclusions. Consequently, we performed a meta-analysis of the existing literature with the aim of identifying significant parameters for a standardized preoperative DLE prediction system. We systematically retrieved articles from the PubMed, Embase, Web of Science, China National Knowledge Infrastructure, and Wanfang databases up to October 2022. Data from eligible studies were extracted and analyzed using the R programming language. The effect measures included odds ratios (ORs) with 95% confidence intervals (CIs) for dichotomous variables and mean differences (MDs) with 95% CIs for continuous variables. The search yielded 1,574 studies, of which 18 (involving a total of 2,263 patients) were included. Pooled analysis demonstrated that patients with DLE during microsurgery tended to be male (OR, 1.73; 95% CI, 1.16-2.57); were older (MD, 5.47 years, 95% CI, 2.44-8.51 years); had a higher body mass index (BMI; MD, 1.19 kg/m2; 95% CI, 0.33-2.05 kg/m2); had a greater neck circumference (MD, 2.50 cm; 95% CI, 1.56-3.44 cm); exhibited limited mouth opening (MD, -0.52 cm; 95% CI, -0.88 to -0.15 cm); had limited neck flexibility (MD, -10.05 cm; 95% CI, -14.10 to -6.00 cm); displayed various other anatomical characteristics; and had a high modified Mallampati index (MMI) or test score (OR, 3.37; 95% CI, 2.07-5.48). We conducted a comprehensive and systematic analysis of the factors relevant to DLE. Ultimately, we identified sex, age, BMI, neck circumference, MMI, inter-incisor gap, hyomental distance, thyromental distance, sternomental distance, and flexion-extension angle as factors highly correlated with DLE.

Bedside preoperative predictors of difficult laryngeal exposure in microlaryngeal surgery.

Successful microlaryngeal surgery relies on an adequate laryngeal exposure. Recognizing the likelihood of challenging exposure prior to microlaryngeal surgery may assist in selecting the appropriate surgical approach and even prompt consideration of alternative treatment options. We aim to apply the mini-Laryngoscore, a preoperative assessment tool, to our study population and incorporate novel variables to optimize the prediction model. This single-center prospective cohort study included 80 consecutive patients undergoing elective microlaryngeal surgery, from January 1, to June 30, 2023. Each patient underwent a presurgical evaluation of 15 parameters and an intraoperative scoring of the anterior commissure visualization. These parameters were assessed for their association with difficult laryngeal exposure, using multiple logistic regression analysis. We created a novel prediction model for DLE and compared it with the existing model, the mini-Laryngoscore. Out of 80 patients, 24 (30%) patients had difficult laryngeal exposure, including 3 cases (3.8%) in which visualization of the anterior commissure was not possible. A large neck diameter (OR, 1.4; CI 1.1-1.9) and the presence of upper teeth (OR, 8.9; CI 1.3-62.8) were independent risk factors for a difficult laryngeal exposure, while a larger interincisors gap was the only independent protector factor (OR, 0.3; CI 0.1-0.8). The logistic regression model combining these three independent risk factors displayed a high discriminative value AUC = 0.89 (CI 0.81-0.97). The predictive performance of the mini-Laryngoscore was 0.73 (CI 0.62-0.85). Combining two parameters from the mini-Laryngoscore (upper jaw dental state and interincisors gap distance) with neck circumference measurement can accurately predict the risk of difficult laryngeal exposure.

Prospective Evaluation and Validation of the Laryngoscore and the mini-Laryngoscore.

The Laryngoscore was described in 2014 as a practical preoperative assessment tool to predict difficult laryngeal exposure (DLE) during transoral approaches to the larynx. In 2019 the authors proposed a version with a reduced number of variables, called the mini-Laryngoscore. We aim to critically appraise and externally validate these two tools and if needed and possible, to optimize these tools. 103 consecutive patients who underwent a microlaryngoscopy between November 2017 and June 2020 at the Leuven University Hospitals were prospectively included and subjected to a presurgical evaluation of 15 parameters and a peroperative scoring of the anterior commissure visualization. Subsequent analysis focused on the concordance of our findings with those of Piazza et al., the discriminatory ability of the test, and the validity of the included items. We then evaluated a modified prediction tool. Of 103 patients, 18 (17.5%) had DLE. The Laryngoscore and mini-Laryngoscore predicted this with a "good" C-index of respectively 0.727 (95%CI: 0.608-0.846) and 0.714 (95%CI: 0.605-0.823). A newly created prediction tool including only three parameters (Interincisors gap, upper jaw dental status and previous treatments) showed a better discriminatory ability (C-index = 0.835, 95%CI: 0.726-0.944) than the original Laryngoscore, a finding that needs further external validation. The original Laryngoscore and the mini-Laryngoscore displayed a good discriminative ability. Some parameters can be left out of the Laryngoscore without losing discrimination. An even better prediction model seems possible, using a weighted sum of selected predictor variables and by using the parameters in their continuous form. 2 Laryngoscope, 134:1807-1812, 2024.

Assessment of Preoperative Predictors for Difficult Laryngeal Exposure in Endolaryngeal Surgery.

The proper visualisation of the larynx is required for the diagnostic assessment and therapeutic intervention. The most significant challenges for surgeon is to visualise the anterior commissure of the glottis region. The aim of this study is to record the preoperative laryngoscore in patients posted for endolaryngeal surgery and to assess preoperative predictors for intraoperative difficult laryngeal exposure by correlating with preoperative laryngoscore. Prospective, Cross-sectional, Observational study. Department of Otorhinolaryngology in a tertiary care teaching facility. 150 patients were included with an endolaryngeal disease who were planned for surgery with age > 18yrs. In 150 subjects preoperative laryngoscore was calculated, which comprised 11 parameters including thyromental distance, mandibular prognathism, macroglossia, micrognathia, trismus, inter incisor gap, degree of neck flexion-extension, history of prior open-neck surgery or radiotherapy, upper jaw dental status, modified Mallampati score and body mass index in order to produce a total score out of a possible maximum score of 17. According to the anterior commissure visualisation all patients were categorised into five classes, ranging from class 0 to class IV during surgery. The laryngoscore parameters were assessed and compared statistically with five classes of intraoperative anterior commissure visualisation. Out of 150 patients 70 (46.6%) were having 3-4 laryngoscore, followed by 45 (30%) patients with 5-6 laryngoscore. Total 123 (82%) patient had class 0,1 and 2 intraoperative anterior commissure visualisation while 27 (18%) had class 3 and 4 visualisation. If laryngoscore was either less or equal to 5, 90% of the patients had excellent laryngeal exposure whereas only 10% of the patients had challenging laryngeal exposure. At univariate analysis, thyromental distance, degree of neck flexion/extension, and modified Mallampati classification were found statistically significant for difficulty of anterior commissure visualisation independently. A sound, easy and valid preoperative laryngoscore may be significantly helpful in identifying intraoperative difficult laryngeal exposure. This may prevent inadequacy of surgery, abandon of surgery, intra operative complication, and medico-legal cases for laryngologist.

Surgical and Functional Outcome After Endoscopic Resection Via Transthyrohyoid for Early Glottic Cancer.

Transthyrohyoid access to the larynx for endoscopic resection (TTER) for early-stage glottic cancer in patients with difficult laryngeal exposure (DLE) has recently been developed. However, little is known about the postoperative conditions of patients. Twelve early-stage glottic cancer patients with DLE who received TTER were retrospectively reviewed. Clinical information was collected during the perioperative period. Functional outcome was evaluated using Voice Handicap Index-10 (VHI-10) and Eating Assessment Tool-10 (EAT-10) preoperatively and 12 months after surgery. None of the patients experienced serious complications after TTER. The tracheotomy tube was removed in all patients. The 3-year local control rate was 91.6%. The VHI-10 score decreased from 18.92 to 11.75 (p < .001), and the EAT-10 scores of the 3 patients changed slightly. Thus, TTER may be a good option for early-stage glottic cancer patients with DLE.

Republication de : Sternum-mental angle: A new predictor of difficult. Laryngeal exposure in suspension microsurgery – An observational study

In our study, we hypothesized that sternum-mental angle (SMA) was a totally new preoperative predictor of difficult laryngeal exposure (DLE). The main objective of this study was to evaluate the diagnostic utility of SMA in predicting DLE in patients undergoing suspension microlaryngeal surgery, and we also searched for risk factors among the selected parameters. A total of 95 patients with vocal cord dysfunction who underwent microlaryngeal surgery were collected. According to the Cormack–Lehane classification method, the patients were divided into non-DLE group ( n = 73) and DLE group ( n = 22). Preoperative assessments included age, sex, body mass index (BMI), Modified Mallampati's index (MMI), neck circumference (NC), thyroid-mental distance at neutral position (TMD-NP), TMD at full extension position (TMD-FE), sternum-mental distance at neutral position (SMD-NP), SMD at full extension position (SMD-FE), SMA at neutral position (SMA-NP) and SMA at full extension position (SMA-FE). SMA was defined as the angle between the horizontal line and the line from upper border of the manubrium sterni to mental prominence, and SMA's ability to predict difficult laryngoscopy was compared with that of established predictors. The DLE incidence of the enrolled patients was 23%. Univariate analysis showed that patients in DLE group presented significantly smaller SMA values. SMA-NP less than 13 provided 68.2% sensitivity and 83.6% specificity and SMA-FE less than 22.5 provided 86.4% sensitivity and 80.8% specificity for the detection of DLE. SMA-FE (≤ 22.5) exhibited the largest area under the curve (AUC: 0.868; 95% CI: 0.784–0.952), confirming its better predictive ability. Binary multivariate logistic regression analyses identified four risk factors including MMI, TMD-FE, TMD-NP which were independently associated with DLE. SMA is a new and simple predictor with a higher level of efficacy, and could help otorhinolaryngologist plan for managements in patients with DLE.

Prediction of difficulty in direct laryngoscopy

To establish easily measurable and reproducible preoperative parameters predicting difficult laryngeal exposure in direct laryngoscopy. A prospective study including 71 patients who underwent transoral microsurgery for benign or malignant lesions of the larynx was performed in our department from January 2021 to November 2021. Physical assessment included the Mallampati score, weight, height, body mass index and measurements of seven parameters in the cervical region. Eleven parameters were measured on the cervical radiography film. Among our patients, 19 were included in the difficult laryngeal exposure (DLE) group. High Mallampati and Cormack scores were significantly associated with DLE (p = 0.005 and p < 0.0001). Limited mouth opening, direct thyromental distance (DTMD) < 67 mm in neutral position, DTMD < 82 mm and sternomental distance < 157 mm at full head extension were statistically related to DLE. For radiological assessment, the effective length of the maxilla and the atlanto-occipital distance were related to DLE. Using stepwise logistic regression, only the effective length of the maxilla and atlanto-occipital distance were selected as independent predictors for DLE (p: 0.015 and 0.001). Preoperative prediction of DLE is useful for both surgeons and patients. The length of the maxilla and the atlanto-occipital distance were found to be independent risk factors for DLE. This highlights the effect of overgrowth of the maxilla, protrusion of the upper teeth and limited extension of the cervical spine as the major risk factors for difficult laryngeal exposure.

Applying a rigid curved video laryngoscope in laryngeal microsurgery of patients with difficult laryngeal exposure

Objective:To test the feasibility of a rigid curved video laryngoscope in laryngeal microsurgery of patients with difficult laryngeal exposure. Methods:Thirteen patients with difficult laryngeal exposure underwent microlayngeal surgery using a new-design rigid curved video laryngoscope. The clinical data were collected and analyzed. Results:In all of the 13 patients with difficult laryngeal exposure,the fully exposure rate of glottis was 100% using a new-design rigid curved laryngoscope.But only 7 precise surgeries using our rigid curved instruments were completed successfully. Conclusion:Rigid curved laryngoscope is a useful tool to in treating patients with difficult laryngeal exposure in microlaryngeal surgery. Satisfactory glottis exposure, magnified surgical field and precise maneuver of the lesions could be achieved. But manipulation of this tool is challenging, which warrants further investigation．.

A Prospective Study to Correlate Difficult Intubation with Difficult Laryngeal Exposure for Microlaryngeal Surgery using Various Grading Scales of Difficult Intubation.

Adequate visualization of the vocal folds is essential for optimal phonosurgery. Pre-operative knowledge of a difficult laryngeal exposure (DLE) can alert the surgeon regarding the need for alternative measures. Our study is based on the hypothesis that a patient who has difficult intubation (DI) is likely to have DLE, thus scales anticipating DI should also anticipate DLE. Our aims were to correlate patients of actual DI on table with patients who had DLE, secondly to assess the ability of grading scales of DI to predict DLE and finally to obtain a cut-off value of neck circumference and length for predicting DLE. This is a prospective, observational study wherein four grading scales; Modified Mallampati Classification (MMC), 3-3-2, Upper lip bite test (ULBT) and Neck Mobility (NM) were used for anticipating DI and correlated with DLE during MLS. Occurrence of actual DI and DLE was correlated. Neck circumference and neck length was correlated with incidence of DLE. Out of 42 patients, 22 were anticipated to have DI (52.38%). Actual incidence of DI was 6 (14.28%) and DLE was 10 (23.80%). Correlation between actual DI and DLE was statistically significant. Of the 4 grading scales, ULBT was significant in predicting DLE. Neck circumference more than 37.5cm and neck length less than 15.3cm was significant in anticipating DLE. There is a significant correlation between DI and DLE. A positive ULBT, neck circumference more than 37.5 cms and neck length less than 15.3 cms are independently suggestive of a DLE.

Magnesium sulfate administration in difficult laryngoscopy: An effective and safe method

PurposeDifficult laryngeal exposure during laryngeal microsurgery and laser surgery is a major concern for otolaryngologists. This study evaluated the efficacy and safety of magnesium sulfate administration in difficult laryngeal exposure patients. Study designQuasi-experimental design. Materials and methodsForty adult patients scheduled for laryngeal microsurgery with difficult laryngeal exposure according to Cormack-Lehane (CL) classification were included. Magnesium sulfate 50% (20–30 mg/kg) was administered as a bolus injection. Laryngeal exposure and hemodynamic stability were evaluated before and after the intervention. ResultsCL grading was shown a statistically significant improvement after magnesium sulfate administration. There are no clinically significant changes in the mean arterial pressure, heart rate, and oxygen saturation levels in the patients who received magnesium sulfate for better laryngeal exposure. ConclusionMagnesium sulfate is an effective and safe drug for better viewing in difficult laryngeal exposure patients.

Phonosurgery of Reinke’s edema with microdebrider

PurposeTo present our experience with a new microsurgical approach for treatment of the Reinke’s edema in suspension laryngoscopy–microdebridement. After a short review of existing literature we introduce speech therapy before and after the surgery into the protocol.Methods The authors compare the phonatory outcome, laryngostroboscopical results and subjective improvement of the voice of 30 patients with Reinke’s edema that were operated with either microdebridement or cold steel surgery techniques. “Sandwich” speech therapy strategy was applied for the vocal rehabilitation before and after surgery in both patient groups.ResultsAfter the microdebridement and the speech therapy the mucosal wave was regular, symmetric and periodic in all patients. No signs of abnormal scar tissue or anterior adhesions were observed. Significant improvement of vocal parameters was found after the surgery in both groups of patients: operated with the microdebridement technique and the cold steel technique. The subjective voice evaluated by Voice Handicap Index (VHI-10) was improved for both patient groups in a homogenous way.ConclusionsBased on the similarity of the vocal outcome in the two groups, microdebridement of the vocal folds is an excellent method for removing the edema of the Reinke’s space. Careful suction at a low voltage protects the lamina propria during the microdebridement. The authors discuss the indication to this innovating procedure in patients with difficult laryngeal exposure and small operating field.

Sternum-mental angle: A new predictor of difficult. Laryngeal exposure in suspension microsurgery – An observational study

ObjectivesIn our study, we hypothesized that sternum-mental angle (SMA) was a totally new preoperative predictor of difficult laryngeal exposure (DLE). The main objective of this study was to evaluate the diagnostic utility of SMA in predicting DLE in patients undergoing suspension microlaryngeal surgery, and we also searched for risk factors among the selected parameters. MethodsA total of 95 patients with vocal cord dysfunction who underwent microlaryngeal surgery were collected. According to the Cormack–Lehane classification method, the patients were divided into non-DLE group (n=73) and DLE group (n=22). Preoperative assessments included age, sex, body mass index (BMI), Modified Mallampati's index (MMI), neck circumference (NC), thyroid-mental distance at neutral position (TMD-NP), TMD at full extension position (TMD-FE), sternum-mental distance at neutral position (SMD-NP), SMD at full extension position (SMD-FE), SMA at neutral position (SMA-NP) and SMA at full extension position (SMA-FE). SMA was defined as the angle between the horizontal line and the line from upper border of the manubrium sterni to mental prominence, and SMA's ability to predict difficult laryngoscopy was compared with that of established predictors. ResultsThe DLE incidence of the enrolled patients was 23%. Univariate analysis showed that patients in DLE group presented significantly smaller SMA values. SMA-NP less than 13 provided 68.2% sensitivity and 83.6% specificity and SMA-FE less than 22.5 provided 86.4% sensitivity and 80.8% specificity for the detection of DLE. SMA-FE (≤22.5) exhibited the largest area under the curve (AUC: 0.868; 95% CI: 0.784–0.952), confirming its better predictive ability. Binary multivariate logistic regression analyses identified four risk factors including MMI, TMD-FE, TMD-NP which were independently associated with DLE. ConclusionsSMA is a new and simple predictor with a higher level of efficacy, and could help otorhinolaryngologist plan for managements in patients with DLE.

A Case of Huge Vocal Polyp in a Patient With Difficult Laryngeal Exposure Treated by Fiberoptic Laryngeal Laser Surgery Under Local Anesthesia

Indications of fiberoptic laryngeal laser surgery (FLS) procedure have broadened by the development of flexible fiberoptic endoscopes and flexible laser systems. FLS procedure performed under local anesthesia and it is the unique value of FLS. The surgery can be performed on patients who are impossible to undergo general anesthesia and difficult to be exposed by laryngeal microsurgery. Main indication of FLS procedure was small to moderate sized hemorrhagic vocal polyp, but we experienced a case of huge vocal polyp with difficult laryngeal exposure treated by FLS procedure under local anesthesia. The vocal polyp was removed successfully without vocal fold scar through fiberoptic laryngeal laser surgery under local anesthesia.

A novel puncture needle designed for endoscopic keel placement to treat anterior glottic webs

Background Endoscopic keel placement is difficult for patients with poor laryngeal exposures. Aims/Objectives To introduce a novel extra-endo laryngeal puncture technique for endoscopic keel placement to manage anterior glottic webs. Material and Methods Patients with anterior glottic webs and difficult laryngeal exposure in our hospital during 2018 to 2020 were recruited in this study. After the incision of the web, a novel puncture needle modified from a maxillary sinus puncture needle was inserted into endolarynx, and could pull the suture passing along a keel from inside out. The suture was then fixated on the neck, and the keel was placed for 4 weeks. Patients were followed up for at least 1 year. Results Eight patients including three men and five women were included in this study. All the patients tolerated the silicone keel well, and 7 of 8 (87.5%) patients did not have web relapses and reached remarkable voice improvements during follow-up. None of the cases needed a tracheotomy due to the dyspnea postoperatively. Conclusions and Significance The novel puncture technique is an easy and effective approach to facilitate endoscopic keel placement for the treatment of anterior glottic webs and other surgical procedures requiring endolaryngeal suturing.

Adding Flexible Instrumentation to a Curved Videolaryngoscope: A Novel Tool for Laryngeal Surgery.

Transoral surgery of the larynx with rigid instruments is not always possible. This may result in insufficient therapy or in an increased need for open surgery. For these patients, alternative surgical systems are needed. Here, we demonstrate a curved prototype for laryngeal surgery equipped with flexible instruments. Pre-clinical user study in an ex vivo porcine laryngeal model. The prototype was built from established medical devices, namely a hyperangulated videolaryngoscope and modified flexible instruments as well as three-dimensional printed parts. Feasibility of laryngeal manipulation was evaluated in a user study (n = 19) with a porcine ex vivo laryngeal model. Using three different visualization technologies, the participants performed various fine motor skills tasks and rated the usability of the system on a 5-point Likert scale. Exposure, accessibility, and manipulation of important laryngeal structures were always possible using the new prototype. The participants needed considerably less time (mean, 96.4 seconds ± 6.4 seconds vs. 111.5 seconds ± 4.5 seconds, P = .18), reported significantly better general impression (mean score 3.0 vs. 3.8, P = .041) and significantly lower user head and neck strain (2.6 vs. 1.7, P = .022) using a 40-inch television screen as compared to a standard videolaryngoscope monitor. The results indicate that our curved prototype and large monitor visualization may provide a cost-effective minimally invasive alternative for difficult laryngeal exposure. Its special advantages include avoiding the need for a straight line of sight and a simple and cost-effective construction. The system could be further improved through advances in camera chip technology and smaller instruments. Laryngoscope, 131:E561-E568, 2021.

Management of Difficult Laryngeal Exposure with Two Surgeons by Using the Flexible Fiberscope

Management of Difficult Laryngeal Exposure with Two Surgeons by Using the Flexible Fiberscope

Treatment of Carcinoma in Situ of Glottis by KTP Fiberoptic Laryngeal Laser Surgery Under Local Anesthesia

The optimal treatments of carcinoma in situ of glottis include radiotherapy, laser surgery and vertical partial laryngectomy. Conventional surgical treatments need general anesthesia and radiotherapy has several complications. Recently, the effectiveness of 532 nm potassium titanyl phosphate (KTP) laser has been proven and widely used in vocal fold diseases even some cases of vocal fold dysplasia. A patient with difficult laryngeal exposure underwent fiberoptic laryngeal laser surgery using KTP laser under local anesthesia, showed improved voice outcome and the glottic lesion was removed successfully without local recurrence and regional metastasis 18 months after surgery. Key words: Carcinoma in situ ㆍ Difficult laryngeal exposure ㆍ Fiberoptic laryngeal laser surgery 핵심용어: 굴곡 내시경 후두 ë ˆì´ì € ìˆ˜ìˆ ã† 성문 ì œìžë¦¬ ì•”ì¢ ã† 경부 ì‹ ì „ 장ì•

A Study of Application of Preoperative Clinical Predictors of Difficult Laryngeal Exposure for Microlaryngoscopy: The Laryngoscore in the Indian Population.

Good exposure for visualisation of the glottis is an essential prerequisite for effective microlaryngoscopy. There is no definitive clinical predictor scoring system to predict difficult microlaryngoscopy. The aim of the study was to study the validity of the Laryngoscore scoring system as a preoperative clinical predictor score in Indian population for difficult laryngeal exposure during microlaryngoscopy. A prospective study was carried out in 32 patients undergoing microlaryngoscopy in a tertiary care hospital who were evaluated by a standardized preoperative assessment protocol (Laryngoscore) which included 11 parameters interincisors gap, thyro-mental distance, upper jaw dental status, trismus, mandibular prognathism, macroglossia, micrognathia, degree of neck flexion-extension, history of previous open-neck and/or radiotherapy, Mallampati's modified score, and body mass index. Each parameter was assessed to obtain a total score (Maximum-17). Patients were divided into five classes according to the anterior commissure visualization: class 0 to class IV. Class 0 being complete and class IV being impossible AC visualization. When the Laryngoscore was < 6, good laryngeal exposure was observed in 94% of patients. Laryngoscore had a sensitivity of 87.5% and specificity of 75% in predicting difficult laryngeal exposure. The positive and negative predictive values of the same are 53.8% and 94.7% respectively. Our study found that the Laryngoscore scoring system as a preoperative indicator for predictor of Difficult Laryngeal Exposure during Micro Laryngeal surgeries is very useful in the Indian population.

Predicting laryngeal exposure in microlaryngoscopy: External validation of the laryngoscore.

Optimal laryngeal exposure during transoral laryngeal surgery is fundamental. We aimed to evaluate the reliability of a recently proposed score (Laryngoscore) in predicting difficult laryngeal exposure (DLE) in an independent cohort of patients undergoing elective microlaryngoscopy. We also verified the relation between DLE, surgeon's expertise, and difficult intubation, and investigated possible areas for score improvement. Prospective validation study. A total of 136 patients were preoperatively evaluated using the Laryngoscore. Patients were divided into three classes according to patient position, type of laryngoscope, and need for external counterpressure to expose the anterior commissure. Based on their mean scores, two groups were identified: good laryngeal exposure (GLE) and DLE. A receiver operating characteristic curve with the Youden index was used to calculate the optimal cutoff value. The χ2 and Fisher exact test were used to correlate GLE and DLE to the surgeon's expertise and difficult intubation. The intraoperative anatomical parameters underlying DLE were also recorded. The optimal cutoff value for differentiating GLE and DLE was 4, which identified 80.6% of DLE cases. No statistically significant difference in GLE and DLE distribution was found between surgeons (P = 0.43). The correlation between difficult intubation and DLE was statistically significant (P = 0.03). The intraoperative parameters determining DLE were epiglottis characteristics (floppy, tight, or short), bulky abdomen and chest, bulky tongue base, mobile teeth, and a narrow laryngeal aditus. The Laryngoscore is reliable for detecting DLE preoperatively. The inclusion of additional parameters may allow a more complete assessment and maximize its diagnostic accuracy. 2b Laryngoscope, 129:1438-1443, 2019.