Identifying risk factors for hospital admission, intensive care unit (ICU) admission, and intubation in patients presenting to the emergency department (ED) with renin-angiotensin-aldosterone system inhibitor (RAASi) induced angioedema. This single hospital-based retrospective cohort study examined ED visits of adult RAASi angioedema patients between January 1, 2006, and August 31, 2016. Clinical events were recorded over the ED visit and the next 2 months. Data extracted included demographics (age, sex, race), symptoms, exam findings, comorbidities, and medication history, intubation details (including difficulty, methods used), and adverse events (hypoxia, cardiac arrest, death). Patient courses, ICU care need, clinical deterioration, therapies, and length of stay were also documented. Of the 755 patients meeting inclusion criteria from our cohort of 1299 patients, 16.2% required intubation during their admission, with 33% admitted to the ICU and 57% to regular hospital floors. Laryngeal swelling was the strongest predictor of adverse outcomes (OR 133.79, p < 0.001), followed by anterior tongue swelling (OR 4.15, p < 0.001), supporting fiberoptic exam as a valuable step in evaluating RAASi angioedema patients. Lip swelling was associated with a decreased likelihood of adverse outcomes such as intubation (OR 0.55, p = 0.049). Shortness of breath did not reliably predict advanced airway outcomes (p = 0.278). Efficiency models incorporating laryngeal swelling, anterior tongue swelling, and body mass index (BMI) achieved excellent predictive performance (AIC 364.43). In the largest study of single-site RAASi angioedema patients who underwent fiberoptic laryngoscopy at admission, we identified key clinical factors for more effectively triaging patients at risk for significant angioedema complications.

Spontaneous neck hematoma is a rare but potentially life-threatening condition due to its risk of rapid airway compromise. It is most commonly associated with aneurysm, infection, thyroid or parathyroid tumors, or underlying coagulopathy, and may also occur in patients receiving anticoagulation or thrombolytic therapy. We report the case of an 87-year-old male with massive pulmonary embolism and deep vein thrombosis who developed a spontaneous cervical hematoma following catheter-directed thrombolysis with alteplase and systemic heparin. The patient presented with progressive neck swelling, ecchymosis, and airway deviation confirmed by contrast-enhanced computed tomography (CT) and flexible fiberoptic laryngoscopy. Airway protection was achieved with endotracheal intubation, and anticoagulation was withheld. He was managed conservatively with intravenous steroids and antibiotics. Extubation was carefully planned using cuff-leak testing, which was successful without the need for surgical intervention. The hematoma resolved gradually, and the patient recovered fully. This case underscores the importance of early recognition, multidisciplinary decision-making, and individualized airway management strategies in optimizing outcomes for spontaneous neck hematoma, especially in anticoagulated patients.

Laryngomalacia is the most common cause of congenital stridor in infants and can lead to feeding difficulties, failure to thrive, and respiratory distress. Diagnosis typically requires flexible fiberoptic laryngoscopy, which more often than not, not available in resource-limited settings. We report a 12-day-old male infant who presented to the emergency department with apnea following a choking episode. He required cardiopulmonary resuscitation and was admitted to the neonatal intensive care unit. Clinical findings included chest retractions, cyanosis, weight loss (from 3500g at birth to 2700g), and feeding difficulties. Chest radiograph showed right-sided perihilar infiltrates consistent with aspiration pneumonia. Despite initial clinical improvement, the infant developed new-onset positional stridor on day ten of hospitalization, particularly when supine. These findings raised strong suspicion of underlying laryngomalacia. These signs raised a strong clinical suspicion of laryngomalacia. Due to absence of flexible fiberoptic laryngoscopy, diagnosis could not be confirmed. The infant was stabilised with supportive care and feeding adjustments before being referred to a tertiary center for definitive evaluation and management. This case highlights the importance of prompt recognition and early stabilisation of neonates with aspiration-related complications and suspected airway anomalies, particularly in low-resource settings. Timely referral is essential to prevent deterioration and guide appropriate long-term management.

Is there a Role for Narrow Band Imaging (NBI) in the Identification of Recurrent Respiratory Papillomatosis (RRP)?

Patient: Male, neonateFinal Diagnosis: Paradoxical vocal fold motion (PVFM)Symptoms: Failure to thrive • feeding problems • inspiratory stridorClinical Procedure: —Specialty: Pediatrics and NeonatologyObjective: Unusual clinical courseBackgroundParadoxical vocal fold motion (PVFM) is characterized by inappropriate adduction of the vocal folds during inspiration, causing inspiratory stridor and feeding challenges. Its nonspecific symptoms and frequent co-occurrence with other conditions make diagnosis challenging. While PVFM is described in older children, neonatal cases remain rare and poorly understood. Limited data exists regarding its incidence, clinical features, and optimal management strategies, and no universally accepted guidelines exist for diagnosing neonatal PVFM.Case ReportThis case describes a term Hispanic male neonate diagnosed with PVFM at 18 days of life. The patient presented with persistent feeding difficulties, inspiratory stridor, and inadequate weight gain, requiring NICU admission. Flexible fiberoptic laryngoscopy (FFL) confirmed intermittent PVFM without structural anomalies. Management included an interdisciplinary care team, who facilitated anti-reflux therapy, gavage feeding, and eventual gastrostomy tube placement for feeding safety and failure to thrive. Despite continued stridor, gradual improvement occurred, with near-complete oral intake by 2 months. Repeat FFL at 68 days after diagnosis demonstrated normal vocal fold mobility.ConclusionsThis case underscores diagnostic challenges and management complexities of neonatal PVFM. FFL remains critical for confirmation, and supportive care with anti-reflux therapy can facilitate resolution. While the precise etiology remains unclear, associations include gastroesophageal reflux disease (GERD), neurological immaturity, and irritant exposure. These factors, combined with lack of definitive etiology, complicate clinical assessment and long-term planning. Standardized guidelines and further research into demographic and clinical predictors of PVFM are needed, especially for neonatal patients.

Background: Autologous fat injection laryngoplasty is a surgical procedure for unilateral vocal fold paralysis (UVFP) to medialize the nonfunctioning vocal fold to allow for complete glottic closure and, thus, improve phonation, protect the airway and improvesymptoms of aspiration and dysphagia. Objective: This study compares the pre-and postoperative voice outcomes of autologous fat injection laryngoplasty in patients with UVFP. Materials and Methods: A prospective observational study was conducted in the Department of Otolaryngology-Head &amp; Neck Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag, Dhaka, from January 2021 to June 2022, with20 patients having UVFP. The subjects were selected based on inclusion and exclusion criteria. Diagnosis of UVFP was identified by indirect laryngoscopy (IL) and confirmed by Fiber Optic Laryngoscopy (FOL). Patients were investigated by Voice Handicap Index (VHI) scores at four-time points: (1) Day before operation (T0), (2) 3 days post injection (T1), (3) 1 month post injection (T2), and (4) 3 months post injection (T3). All the VHI information was recorded in a prefixed questionnaire to analyze and calculatethe results. Results: The age of the patients ranged from 19-55 years, with a mean age of 38.8±9.93 years. Among them, 13 were female (65%), and 7 were male (35%). Male: Female ratio was 1:1.8. Most patients (55%) had thyroid surgery, and the rest were idiopathic (45%). 75% of the vocal cord are paralyzed on the left side and 25% on the right-sided. The VHI scores improved significantly from 75.85±13.04 preoperatively to 58.70±12.38 at 3 days postoperatively (P &lt; 0.0001); 47.50±9.51 at 1 month postoperatively (P &lt; 0.0001), and 37.35±8.50 at 3 months postoperatively (P &lt; 0.0001). Conclusion: Autologous fat injection laryngoplasty is a simple, safe, and cost-effective temporary phonosurgical procedure for the treatment of unilateral vocal fold paralysis, thus improving acoustic and voice-related quality of life (QOL). Bangladesh J Otorhinolaryngology 2025; 31 (1) Page- 05-15

Supraglottic airway devices in awake tracheal intubation: a viable alternative to fiberoptic and video laryngoscopy

Medialization Thyroplasty with Tensor Fascia Lata for Immunocompromised or Irradiated Patients.

Predicting surgical intervention in infants with laryngomalacia.

Comparative evaluation of ultrasound and fiberoptic laryngoscopy results in pediatric thyroid surgery

To evaluate the diagnostic accuracy of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), Pediatric Voice Handicap Index (pVHI), and computer-assisted voice analysis (CVA) against flexible fiberoptic laryngoscopy in a pediatric cohort. A retrospective cohort of 116 children (4-18 years) underwent same-day CAPE-V, pVHI, CVA (Visipitch), and flexible fiberoptic laryngoscopy at a tertiary pediatric voice clinic. Encounters were classified as dysphonia evaluation versus vocal fold surveillance, and age was grouped as preschool (≤ 5 years) versus school-aged (> 5 years). Diagnostic performance was assessed with receiver operating characteristic (ROC) curves, area under the curve (AUC), and optimal cutpoints by the Youden index. Multivariable logistic regression-adjusted for age category and encounter type-modeled odds of abnormal endoscopic findings. CAPE-V demonstrated the highest individual accuracy (AUC 0.827; p = 0.0034). Combined use of CAPE-V, pVHI, and CVA yielded superior discrimination (AUC 0.846; sensitivity 0.886; specificity 0.771; positive predictive value 0.886; negative predictive value 0.771). Dysphonia encounters had lower odds of abnormal findings compared to vocal fold surveillance (OR 0.09; 95% CI 0.02-0.36). School-aged children had lower odds of pathology than preschoolers (OR 0.18; 95% CI 0.03-0.09). Peak sensitivity occurred at Age 7; the probability of abnormal findings declined with increasing age. CAPE-V is a robust single-test predictor of pediatric vocal fold pathology, and integration with pVHI and CVA enhances diagnostic accuracy. A tiered, age-tailored screening algorithm beginning with CAPE-V may optimize referral pathways and improve early detection of vocal fold pathology while preserving laryngoscopy as the diagnostic standard. Level 3 (retrospective cohort study).

Acoustic Analysis of the Normal Voice in Classically Trained Vocal Professionals: A Cross-sectional Study.

Endotracheal intubation is a routine yet critical procedure during general anesthesia that can cause a spectrum of laryngeal injuries, potentially affecting vocal function and airway integrity. The route of intubation, oral versus nasal, may influence the incidence and severity of such injuries, but evidence is inconclusive. This study aims to prospectively compare the incidence, severity, and clinical impact of laryngeal injuries following oral and nasal intubation in adult patients undergoing elective surgeries under general anesthesia. A prospective observational study was conducted involving 67 patients scheduled for elective surgery with endotracheal intubation. Patients were allocated into oral (n = 35) and nasal (n = 32) intubation groups based on surgical requirements. Flexible fiberoptic laryngoscopy was performed within six hours of extubation to evaluate laryngeal injuries, graded using the Eckerbom classification. Hoarseness severity was assessed and recorded. Statistical analysis including chi-square tests and multivariate logistic regression identified predictors of injury and compared groups, with significance set at p < 0.05. The incidence and severity of laryngeal injuries did not significantly differ between oral and nasal intubation groups (p = 0.67). Grade 0 injury (no visible abnormality) was predominant (oral 65.7%, nasal 71.9%). Hoarseness severity distribution was also comparable (p = 0.78). Multivariate analysis revealed no significant association between injury occurrence and variables including tube size, duration of intubation, or number of intubation attempts. Oral and nasal routes of endotracheal intubation demonstrated comparable rates and severity of post-intubation laryngeal injuries in this cohort. Skilled intubation technique remains paramount to minimizing complications regardless of route.

Difficult intubation is a challenge for an Anesthesiologist. Expertise in effective airway management which includes initial assessment to follow-up care. In this article we reported a 58-year-old male with a history of tracheostomy, craniotomy, and Open Reduction and Internal Fixation (ORIF) placement on the maxilla dextra, who will undergo a cranioplasty procedure under general anaesthesia. On physical examination, a mallampati class IV assessment was obtained, the distance between incisors &lt; 3 fingers. The pre-anesthesia assessment an American Society of Anesthesiologist (ASA) II with LEMON score of 4. The intraoperative process used intravenous induction with fentanyl 150 mg, midazolam 5 mg, Propofol 150 mg, and Rocuronium 50 mg. Two airway management scenarios in this patient failed, which were video-assisted laryngoscopy and fibre optic laryngoscopy, therefore a third scenario was performed using retrograde intubation technique. Retrograde intubation is an effective alternative in patients with intubation difficulties.

Voice and Swallowing Dysfunction Associated With Extracorporeal Membrane Oxygenation in Pediatric Patients.

We present the case of a patient with bilateral vocal fold paralysis following extensive surgical repair of congenital cardiac abnormalities and the management of the subsequent airway compromise with primary endoscopic anterior-posterior cricoid split. Review of our management of a patient with bilateral vocal fold paralysis using anterior-posterior cricoid split and literature search of alternative management options for patients with bilateral vocal fold paralysis. Our newborn patient developed stridor and respiratory failure following surgery for multiple cardiac malformations. Flexible fiberoptic laryngoscopy revealed bilateral vocal fold paralysis, and the patient was intubated for airway protection. We addressed the bilateral vocal fold paralysis with primary endoscopic anterior-posterior cricoid split to avoid tracheostomy, successfully extubating to room air 13 days later. The patient regained nearly total function of both folds and, at two-year follow-up, was asymptomatic from an airway, voice, sleep and swallowing perspective. APCS was effective in managing bilateral vocal fold paralysis-associated respiratory failure and avoiding tracheostomy, with long-term follow-up demonstrating symptom resolution and bilateral recovery of laryngeal mobility.

Introduction. Diffuse symmetric lipomatosis (Madelung’s disease) is a rare and poorly understood disorder. This condition is characterized by diffuse proliferation of adipose tissue, leading to significant functional and aesthetic impairments. The documentation of clinical cases is essential to improve understanding of this pathology and formulate efficacious therapeutic strategies relevant to general practitioners, oncologists, otolaryngologists, neurologists, and thoracic surgeons. Aim. This study reports the findings from clinical observation in a 63-year-old patient with diffuse symmetric lipomatosis involving the neck, with intermuscular infiltration and compression of upper airways. We present an example of surgical management and subsequent follow-up care for such patients. Materials and methods. This article reports the treatment outcome of a 63-year-old male patient with substantial diffuse proliferation of adipose tissue in the neck region. The clinical, instrumental, and laboratory investigations included magnetic resonance imaging (MRI), fiberoptic bronchoscopy, fiberoptic laryngoscopy, fiberoptic gastroduodenoscopy, and fine-needle aspiration biopsy (FNAB). The surgical intervention involved open lipectomy with subsequent histopathological examination of the resected tissue. Results and discussion. The patient initially presented with substantial diffuse proliferation of adipose tissue affecting neck mobility and inducing symptoms related to airway compression. MRI revealed systemic benign lipomatosis, without significant cervical or mediastinal lymphadenopathy. The surgical intervention involved the removal of 1,800 grams of adipose tissue through an open lipectomy. In the postoperative period, the patient reported significant improvements in breathing, enhanced neck mobility, and a satisfactory cosmetic effect. However, disease recurrence was observed three years after surgery. Conclusion. This case report confirms the efficacy of open lipectomy as a treatment option for Madelung’s disease, particularly for relieving airway compression symptoms. However, the high risk of recurrence underscores the need for further investigation to formulate long-term management strategies for this condition.

Emergency Airway Management in a Patient With Tracheoesophageal Fistula and Prior Laryngectomy.

Objectives were to characterize patients with inducible laryngeal obstruction (ILO), evaluate exercise-induced asthma (EIA) test results, and determine the need for future testing in this population. A retrospective chart review was performed at a tertiary children's hospital on all pediatric patients seen in the Vocal Cord Dysfunction specialty clinic from February 2018 to February 2020. Demographics, medications, comorbidities, ILO triggers, symptoms, EIA test results, and follow-up otolaryngology and pulmonology appointment information were collected. Sixty-eight patients with ILO were identified at a median age of 14.5 (range: 9-18) years. Most were female (n = 50, 73.5%) and white (n = 65, 95.6%). Nearly all (92.6%) patients were triggered by exercise and 72.1% by laryngopharyngeal reflux. Almost all (98.5%) patients described difficulty breathing when triggered, with a third (35.3%) having stridor. Median time from initial symptoms to presentation was 12 months (range: 3 months-10 years) and median episode duration was 5 minutes (range: 30 seconds-3 hours). EIA testing was performed in 82.4%. Most (96.4%) patients did not exhibit an ILO episode during flexible fiberoptic laryngoscopy. ILO benefits from a multidisciplinary team approach. Patients were triggered primarily by exertion or reflux, though the underlying behavioral health predispositions have not fully been explored.

BackgroundLaryngeal ultrasound (LUS) is a noninvasive, painless, and radiation-free imaging method that presents a promising alternative, especially for the dynamic assessment of laryngeal structures. It can also be utilized by general practitioners. This study assesses the diagnostic accuracy, patient comfort, and cost-effectiveness of LUS compared to flexible fiberoptic laryngoscopy (FFL) for diagnosing laryngomalacia in infants aged ≤ 2 years with stridor-specific airway issues.MethodsA total of 43 infants presented with inspiratory stridor or other airway symptoms and underwent assessments using both flexible fiberoptic laryngoscopy and laryngeal ultrasound. Laryngomalacia was diagnosed based on a vocal fold–arytenoid abduction angle of ≤120° and arytenoid and/or vocal fold collapse during inspiration. The diagnostic performance of LUS was compared with FFL, and the severity of the disease was evaluated. Both the pediatric endoscopist and radiologist were blinded to the patients’ diagnoses and study results.ResultsA total of participants was included in the study, comprising 35% males and 65% females. The mean age of 4.52 ± 5.44 months and the mean weight of 4.62 ± 2.23 kg. Laryngomalacia was diagnosed in 60% of cases using FFL, with seven infants requiring surgical intervention; all were also identified as having laryngomalacia via LUS. LUS demonstrated diagnostic efficiency for laryngomalacia in 7 out of 19 infants, with a sensitivity of 26.92%, specificity of 100%, negative predictive value of 47.22%, and positive predictive value of 100%. The overall diagnostic accuracy of LUS was 55.8%.ConclusionWhile LUS cannot replace FFL as the primary diagnostic tool for infant laryngomalacia, it serves as a valuable adjunct for follow-up assessments and for identifying moderate to severe cases that may require surgical intervention. Further research and advancements in ultrasound technology may enhance diagnostic accuracy and broaden clinical applications for general practitioners.