Flexible Fiberoptic Endoscopy Research Articles

VALIDATION OF A LOW-COST METHOD FOR RECORDING AND SUPERVISING OTOLARYNGOLOGY TRAINEE ENDOSCOPIES,

Objectives/HypothesisTo design low-cost smartphone adaptors for recording otolaryngology trainee and physician extender endoscopies and evaluate their image quality and usability in the inpatient and emergency room (ER) settings. Study DesignProspective mixed-methods study, including device design, quantitative and qualitative surveys Methods3D-printed adaptors for rigid and flexible fiberoptic endoscopy were iteratively developed. Three versions of the adaptors were provided to otolaryngology trainees, faculty and physician extenders: phone adaptors +/- telescope magnification and tablet/laptop adaptors featuring a USB camera. Surveys including the System Usability Scale (SUS) and questions on image quality, ease of use, and impact on patient care were administered. Images from the adaptors and existing recording methods were compared using the BRISQUE image quality metric. Results20 otolaryngology staff completed the survey (9 residents, 1 physician assistant, 9 attendings, 1 fellow). SUS scores were excellent with a mean of 77.5 (SD 9.7). There were no significant differences in BRISQUE scores when comparing the smartphone adaptors with single-use distal-chip nasopharyngolaryngoscopes and clinic fiberoptic systems (F=0.7, df=4, p=0.5890). The cost to fabricate the phone adaptor with/without a telescope, and the tablet/laptop adaptor was $1.28, $39.38, and $93.84, respectively. Responses to semi-structured questions highlighted positive impact on supervision and collaboration. ConclusionsThere are limited options for recording and supervising otolaryngology trainee endoscopic exams in the inpatient and ER settings. Endoscopic phone adaptors designed by 3D printing can generate sufficient image quality and usability for clinical supervision.

Disinfection of flexible fibre-optic endoscopes out-of-hours: confidential telephone survey of ENT units in England - 20 years on.

Flexible upper aerodigestive endoscopy is often performed in the emergency setting. To prevent nosocomial infection on-call clinicians must have access to decontaminated endoscopes. A telephone survey of 104 ENT units in England replicated previous cycles conducted 10 and 20 years ago. The on-call clinician was asked about decontamination practices, training and cross-cover. Seventy-one clinicians participated of which 68 had an endoscope available out-of-hours. Twenty-five (36.8 per cent) used single-use endoscopes. Twenty-three (51.1 per cent) of the 45 clinicians using re-usable endoscopes decontaminated them themselves, an increase from 43.3 per cent in 2013 and from 35.1 per cent in 2002. Overall 91.2 per cent had safe practices, up from 68.7 per cent in 2013 and 48 per cent in 2002. One hundred per cent had been trained in decontamination, compared to 37.3 per cent in 2013 and 12.1 per cent in 2002. On-call clinicians from the ENT department increased to 91.5 per cent, compared to 63 per cent in 2013. There has been a dramatic increase in patient safety, underpinned by the introduction of single-use endoscopes, increased training and reduced cross-cover.

Prevalence of Post-extubation Airway Penetration and Aspiration among Critically Ill Patients Assessed by an Eight-point Penetration-Aspiration Scale Using Flexible Endoscopy: A Cross-sectional Study.

Prolonged endotracheal intubation was found to be a risk factor for pulmonary aspiration following the extubation. In this study, we have tried to analyze the prevalence of airway penetration and aspiration among mechanically ventilated patient who received mechanical ventilation for a period of 48 hours or more. This cross-sectional study was done among non-neurologic critically ill patients who had an endotracheal tube for more than 48 hours and who got extubated subsequently. Such patients were taken for a fiberoptic endoscopic swallow study after the initial assessment by a speech pathologist. Airway penetration and aspiration was assessed by an eight-point penetration-aspiration scale after giving a test feed. Data of 99 patients were analyzed. Mean duration of intubation was 5.9 days. 1% of the patients had aspiration and 20% of the patients had varying degrees of penetration. Duration of endotracheal intubation, age, sex, comorbidities, admission diagnosis, and size of the endotracheal tube were found to have no association with penetration and aspiration. Prevalence of post-extubation aspiration was low among non-neurologic critically ill patients on short-term ventilation. Duration of endotracheal intubation, age, sex, comorbidities, and endotracheal tube size were not found to be significantly associated with the development of airway penetration. Contrary to previous studies, this study has shown that among non-neurologic critically ill patients who had an endotracheal tube for a shorter period before extubation, the prevalence of airway penetration and aspiration was low when assessed by an eight-point penetration-aspiration scale using flexible fiberoptic endoscopy. Hence, in such a cohort of patients, a routine swallowing evaluation by flexible endoscopy is not recommended. Vijayan D, Suresh Kumar VK, Harikrishnanan, Menon J, Ragitha, Jacob M, et al. Prevalence of Post-extubation Airway Penetration and Aspiration among Critically Ill Patients Assessed by an Eight-point Penetration-Aspiration Scale Using Flexible Endoscopy: A Cross-sectional Study. Indian J Crit Care Med 2023;27(9):651-654.

Critical Stenosis Because of Vocal Cord Synechiae in a Child

Stridor is a clinical sign of an underlying disease and a common reason for pediatric emergency department (PED) consultation. Patients presenting with stridor must be evaluated to determine the origin of this abnormality. We present the case of a 7-year-old female patient who presented to our Pediatric Emergency Department with a history of recurrent episodes of stridor with increasing frequency over the previous 4 years, for this reason she was previously admitted to the pediatric intensive care unit. Findings from the otorhinolaryngologic assessment with flexible fiber-optic endoscopy led to a diagnosis of congenital synechia of the vocal cords. The cervical CT scan evidenced critical stenosis of the airway. An initial cordectomy and placement of a silicone device for fixation were performed. Subsequently, the patient required 6 additional interventions for progressive dilation of the glottic space at the level of the vocal cords and injections of mitomycin C injections (an antineoplastic that inhibits collagen proliferation). This case highlights the importance of additional studies (especially examination of the upper airway) when atypical or recurrent findings are revealed by the clinical history, physical examination, or disease course in patients with croup to prioritize cases severe enough to require pediatric intensive care unit admission.

Three Cases of Foreign Bodies in the Hypopharynx and Esophagus Removed Using Sato Rigid Curved Laryngoscope

There are many cases of foreign bodies in the hypopharynx or esophagus that are removed using a flexible fiberoptic upper gastrointestinal endoscope, however, there are also cases in which, due to the shape and size of the foreign body and/or the anatomical problems, it is difficult to remove foreign bodies using a flexible fiberoptic endoscope. Conventional rigid esophagoscopy can sometimes be difficult due to the problem of a narrow visual field. In these case, the Sato rigid curved laryngoscope strongly lifts the larynx and provides a wide field of view and space at the entrance of the esophagus from the hypopharynx.

One Lung Extraluminal Bronchial Blocker

Introduction: This video shows the various methods employed for one lung ventilation (OLV) for thoracoscopic surgery in infants and toddlers. Currently, there are no best practice guidelines on the best method to achieve OLV in this challenging patient population. The different methods include main stem intubation, double lumen tubes, and extraluminal bronchial blockers.1 Extraluminal bronchial blocker for OLV has unique advantages for infants and smaller children that balances the needs of both the surgical and anesthesia providers. We demonstrate a standard method for extraluminal bronchial blocker placement in an infant and a novel modification of the technique that facilitates more accurate blocker placement into the target bronchus.2 The rationale for a multicenter study of OLV techniques in infants is presented as next steps are discussed. Materials and Methods: A novel modification for the technique of extraluminal bronchial blocker for OLV using an uncuffed tube facilitates deployment of the bronchial blocker. To start, the endotracheal tube (ET) here is placed through video laryngoscopy. A flexible fiberoptic endoscope is then used to ensure correct placement into the left main stem. The bronchial blocker is then deployed directly into the left mainstem through the main stemmed endotracheal tube. While holding the blocker in place, The ET tube is then removed from the trachea over the external portion of the blocker shaft. Next, under direct or video laryngoscopy, a new ET tube is positioned in the trachea and anterior to the now extraluminal/endotracheal bronchial blocker. Flexible bronchoscopy through the ET tube is then used to observe the bronchial blocker in the left bronchus and the balloon is inflated once placement is confirmed. Results: Effective placement of extraluminal bronchial blockers into the left mainstem can be achieved with this novel modification to placement. Conclusions: The primary literature on this subject is limited and there are no best practice guidelines at this time. Small single-center studies have shown that extraluminal bronchial blockers are associated with less hypoxemia and hypercarbia.3 The novel modification to the placement of extraluminal bronchial blockers described in this video may help with ease of placement and encourage wider adoption of this technique. There is a need for multicenter study to adequately determine the most effective method for OLV that maximizes the safety profile for patients, ensures ease of placement for the anesthesia providers, and maintains quality lung isolation for the surgeon. No competing financial interests exist. Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 5 mins

Peptic ulcer disease among dyspeptic patients at endoscopy unit, University of Gondar hospital, Northwest Ethiopia

BackgroundDyspepsia is a common complaint in upper gastrointestinal disorders. It is described as predominant epigastric pain lasting for at least one month. Globally, peptic ulcer disease occurs in 3.5–32% of patients with dyspepsia. Helicobacter pylori (H. pylori) infection and non-steroidal anti-inflammatory drugs/aspirin use are the widely known risk factors for peptic ulcer disease. There was no recent document on H. pylori infection rate among patients with peptic ulcer disease in Ethiopia. This study aimed to determine magnitude and associated factors of peptic ulcer disease among dyspeptic patients in Northwest Ethiopia.MethodsAn institutional-based cross sectional study was conducted at the University of Gondar hospital, Northwest Ethiopia. A convenience sampling method was used to recruit 218 study subjects. A pre-designed semi-structured questionnaire was used to extract clinical information. Olympus flexible fiber-optic endoscope (Olympus, GIF-E 600, Olympus Corp., Hamburg, Germany) was used to confirm the presence of peptic ulcer disease. Diagnosis of active H. pylori infection was made using the fecal H. pylori Antigen 25 T Card Test (Anamol Lab., Pvt. Ltd., Palghar, India). The Data were entered into EPI Info version 4.6.0.2, and then exported to SPSS version 20 for analysis. Explanatory variables associated with peptic ulcer disease were analyzed by applying logistic regression model. P value < 0.05 was used to declare significant association.ResultA total of 218 dyspeptic patients who underwent upper gastrointestinal endoscopic evaluations were included in the study. The mean (+ SD) age of patients was 42 ± 16.4 years. Forty nine percent (95% CI 42.4–56.2) of dyspeptic patients had active H. pylori infection. Peptic ulcer disease was diagnosed in 35% (95% CI 31.4–39.2) of patients with dyspepsia. H. pylori infection (AOR = 6.298, 95% CI 2.965–13.378, P value < 0.001) and NSAIDs/ASA use (AOR = 6.252, 95% CI 2.925–13.362, P value < 0.001) were identified as risk factors for peptic ulcer disease.ConclusionMedical treatment of peptic ulcer disease should target treatment of H. pylori infection and cautious use of non-steroidal anti-inflammatory drugs/aspirin.

Detection of Vocal Fold Image Obstructions in High-Speed Videoendoscopy During Connected Speech in Adductor Spasmodic Dysphonia: A Convolutional Neural Networks Approach

Adductor spasmodic dysphonia (AdSD) is a neurogenic voice disorder, affecting the intrinsic laryngeal muscle control. AdSD leads to involuntary laryngeal spasms and only reveals during connected speech. Laryngeal high-speed videoendoscopy (HSV) coupled with a flexible fiberoptic endoscope provides a unique opportunity to study voice production and visualize the vocal fold vibrations in AdSD during speech. The goal of this study is to automatically detect instances during which the image of the vocal folds is optically obstructed in HSV recordings obtained during connected speech. HSV data were recorded from vocally normal adults and patients with AdSD during reading of the "Rainbow Passage", six CAPE-V sentences, and production of the vowel /i/. A convolutional neural network was developed and trained as a classifier to detect obstructed/unobstructed vocal folds in HSV frames. Manually labelled data were used for training, validating, and testing of the network. Moreover, a comprehensive robustness evaluation was conducted to compare the performance of the developed classifier and visual analysis of HSV data. The developed convolutional neural network was able to automatically detect the vocal fold obstructions in HSV data in vocally normal participants and AdSD patients. The trained network was tested successfully and showed an overall classification accuracy of 94.18% on the testing dataset. The robustness evaluation showed an average overall accuracy of 94.81% on a massive number of HSV frames demonstrating the high robustness of the introduced technique while keeping a high level of accuracy. The proposed approach can be used for efficient analysis of HSV data to study laryngeal maneuvers in patients with AdSD during connected speech. Additionally, this method will facilitate development of vocal fold vibratory measures for HSV frames with an unobstructed view of the vocal folds. Indicating parts of connected speech that provide an unobstructed view of the vocal folds can be used for developing optimal passages for precise HSV examination during connected speech and subject-specific clinical voice assessment protocols.

Comparison of Drug-Induced Sleep Endoscopy and Natural Sleep Endoscopy in the Assessment of Upper Airway Pathophysiology During Sleep: Protocol and Study Design.

Study Objectives: Obstructive sleep apnea (OSA) is increasingly recognized as a complex and heterogenous disorder. As a result, a “one-size-fits-all” management approach should be avoided. Therefore, evaluation of pathophysiological endotyping in OSA patients is emphasized, with upper airway collapse during sleep as one of the main features. To assess the site(s) and pattern(s) of upper airway collapse, natural sleep endoscopy (NSE) is defined as the gold standard. As NSE is labor-intensive and time-consuming, it is not feasible in routine practice. Instead, drug-induced sleep endoscopy (DISE) is the most frequently used technique and can be considered as the clinical standard. Flow shape and snoring analysis are non-invasive measurement techniques, yet are still evolving. Although DISE is used as the clinical alternative to assess upper airway collapse, associations between DISE and NSE observations, and associated flow and snoring signals, have not been quantified satisfactorily. In the current project we aim to compare upper airway collapse identified in patients with OSA using endoscopic techniques as well as flow shape analysis and analysis of tracheal snoring sounds between natural and drug-induced sleep.Methods: This study is a blinded prospective comparative multicenter cohort study. The study population will consist of adult patients with a recent diagnosis of OSA. Eligible patients will undergo a polysomnography (PSG) with NSE overnight and a DISE within 3 months. During DISE the upper airway is assessed under sedation by an experienced ear, nose, throat (ENT) surgeon using a flexible fiberoptic endoscope in the operating theater. In contrast to DISE, NSE is performed during natural sleep using a pediatric bronchoscope. During research DISE and NSE, the standard set-up is expanded with additional PSG measurements, including gold standard flow and analysis of tracheal snoring sounds.Conclusions: This project will be one of the first studies to formally compare collapse patterns during natural and drug-induced sleep. Moreover, this will be, to the authors' best knowledge, the first comparative research in airflow shape and tracheal snoring sounds analysis between DISE and NSE. These novel and non-invasive diagnostic methods studying upper airway mechanics during sleep will be simultaneously validated against DISE and NSE.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04729478.

ADENOID SIZE IN CHILDREN WITH OTITIS MEDIA WITH EFFUSION.

SUMMARYOtitis media with effusion (OME) is amongst the most common pediatric diseases and the most common cause of hearing loss in children. It is accepted that adenoid hypertrophy (AH) is related to OME incidence. Better understanding of the correlation between the relative size of AH and the incidence of persistent OME may provide evidence to support a more standardized approach to the diagnosis and treatment of OME. A retrospective study carried out between April 2016 and April 2018 collected data on 65 children aged 2-12 years, diagnosed with chronic OME and symptoms of AH, where conservative therapy failed. Pre-diagnostic data were collected from patient history, otoscopy, rhinoscopy, and oropharyngoscopy findings. Diagnostic workup included tympanometry, audiometry, and flexible nasal fiberoptic endoscopy. Adenoid grading was performed according to Cassano method after endoscopic visualization. Of the 65 patients, 37 were male and 28 were female. There was no statistically significant difference according to gender or average age. The highest incidence of persistent OME with AH was recorded in the youngest age groups (2-5 and 6-9 years). The most frequent AH grades were grade II (35.38%) and grade III (50.77%), yielding a statistically significant result. The most common presenting symptoms were hearing impairment, snoring, and nasal obstruction (100%, 64.62% and 60%, respectively). Higher AH grades are critical for persistence of OME and may cause conservative therapy failure.

Targeted fibre-optical intrabronchial lipopolysaccharide administration in pigs – a methodical refinement for improved accuracy in respiratory research

ObjectiveTo establish and evaluate a standardized method of targeted, intrabronchial drug delivery in pigs. Study designRandomized controlled trial. AnimalsA total of 16 German Landrace pigs (Sus scrofa), age range 12‒16 weeks, and weighing 28‒35 kg. MethodsThe animals were anaesthetized, intubated, and instrumented with extended cardiovascular monitoring. Lung injury was induced by administering via a flexible fibre-optic endoscope using 100 mL saline solution containing either 20 mg of Escherichia coli lipopolysaccharide (E. coli LPS) (n = 8) or no additive (sham, n = 8) into the two distal mainstem bronchi. The animals were monitored for 8 hours and arterial oxygenation, inspiratory pressure and arterial blood pressure were measured repeatedly. Post-mortem, lung tissue was prepared for histologic damage scoring and determination of proinflammatory cytokines Interleukin-6 (IL-6) and tumour necrosis factor alpha (TNFα). Statistical analyses were performed using inter-group analysis of variance and Student’s t tests. Data are presented as mean ± standard deviation. A p value <0.05 was considered significant. ResultsThe targeted application of LPS led to significant deterioration of oxygenation consistent with mild-to-moderate acute respiratory distress syndrome (ARDS) and hypotension (Horowitz ratio: sham 2 hour, 300 ± 39; LPS 2 hour, 193.7 ± 52; p < 0.001). Histologic analyses identified increased inflammation and oedema in the tissues of the animals in the LPS group IL-6 sham: 6.4 ± 4.4 × 10–5 pg mL–1; IL-6 LPS: 2.8 ± 2.4 × 10–4 pg mL–1, p = 0.015. ConclusionsThe targeted application of agents via flexible fibre-optic endoscopy is a valid, reliable method of causing controlled lung damage in a porcine model. The data presented suggest the feasibility and possible advantages of controlled application and could expand the array of techniques used to help understand the critical condition of ARDS. In addition, a targeted approach could help reduce animal numbers used for this purpose.

Lack of Evidence of Transmission of Bloodborne Viruses by Improperly Reprocessed Fiberoptic Endoscopes

Background: A sterile processing service (SPS) technician was found to inadequately clean fiberoptic endoscope channels during reprocessing prior to high-level disinfection. Channels were only brushed once and 7 of 30 audited scopes had measurable bioburden. Consistent with VA policy, a retrospective investigation, along with public disclosure, was performed. Methods: A potentially exposed case (PEC) was defined as any patient who had flexible fiberoptic endoscopy between April 19, 2015, and June 23, 2017, when the identified SPS technician worked in the endoscope reprocessing station. Using the internal log of the automated high–level disinfection equipment (Medivators/Cantel, Minneapolis, MN), device serial numbers were matched to patients in endoscopy suite procedure logs. Additionally, the VA Corporate Data Warehouse (CDW) was queried for CPT and International Classification of Disease, Ninth Revision (ICD-9) and ICD-10 procedure codes to verify identified cases and to search for other PECs. All PECs were notified by telephone and mail, and serologic testing for human immunodeficiency virus (HIV-1), hepatitis C virus (HCV), and hepatitis B virus (HBV) was offered. Results were compared to prior bloodborne pathogen (BBP) testing results extracted from the CDW. Facility microbiology laboratory records of positive cultures/microscopy for enteric pathogens also were compared to the list of PECs; no active testing was performed. Results: Of the 565 PECs, 552 (98%) were successfully contacted. 8 declined testing or preferred non-VA testing, and 22 died before testing could be initiated. Repeat testing at 6 months was requested for PECs who had initial testing performed &lt;6 months after exposure; 32 refused additional tests or did not respond to additional requests. In total, 522 PECs (92%) had testing performed for 1 or more BBPs: (1) 521 were anti–HIV negative with 1 previously known positive; (2) 481 were anti–HCV negative—43 were previously known positive and 1 PEC with an undetectable HCV viral load was newly identified; (3) 461 were negative for both HBV core or surface antibodies and surface antigen—32 were previously known positive and 17 were newly positive for one or both antibody tests with negative HBV surface antigen. Of 17 newly identified positive PECs, 16 had undetectable HBV DNA; 1 died prior to HBV DNA testing. Conclusions: There was no evidence of transmission of BBPs in this cohort of PECs who had procedures with potentially improperly cleaned fiberoptic endoscopes. Although not all patients completed all retrospective BBP testing, &lt;10% were missing all or some tests. Local passive surveillance did not indicate enteric pathogen transmission. Additional education regarding and monitoring of reprocessing procedures have been instituted.Funding: NoneDisclosures: None

Patient-Worn Enhanced Protection Face Shield for Flexible Endoscopy.

The primary objective of this study was to compare the protection afforded by a standard face shield design with a new enhanced design in a controlled setting. This study was exempted from review by institutional review board waiver. A flexible fiberoptic endoscopy was placed through stellate openings in the standard face shield and the enhanced face shield. A series of simulated coughs were created with bursts of fluorescein dye through an atomizer tip placed within the test participant's mouth. Ultraviolet lighting illuminated the test area, and areas of dye splatter were noted. Fluorescein dye is easily aerosolized along the lateral inferior aspect of a standard shield with significant contamination of the surrounds. The enhanced face shield maintained a barrier to the aerosolized dye. Face shields, rather than face masks, should be considered a preferred alternative for the public and for health care professionals alike, as they address many of the personal protective equipment concerns especially during the COVID-19 pandemic. Otolaryngologists are at high risk from aerosol-generating procedures, such as flexible fiberoptic endoscopy, even when wearing personal protective equipment. Here we describe a uniquely designed face shield to be worn by the patient as another layer of protection for the environment and for medical personnel. During the course of a flexible fiberoptic endoscopy, medical personnel are safely isolated from potential infectious particles with a newly designed face shield.

Assessment and Diagnostic Accuracy Evaluation of the Reflux Symptom Index (RSI) Scale: Psychometric Properties using Optimal Scaling Techniques.

To investigate the psychometric properties of the reflux symptom index (RSI) as short screening approach for the diagnostic of laryngopharyngeal reflux (LPR) in patients with confirmed diagnosed regarding the 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH). From January 2017 to December 2018, 56 patients with LPR symptoms and 71 healthy individuals (control group) were prospectively enrolled. The LPR diagnosis was confirmed through MII-pH results. All subjects (n = 127) fulfilled RSI and the Reflux Finding Score (RFS) was performed through flexible fiberoptic endoscopy. The sensitivity and the specificity of RSI was assessed by ROC (Receiver Operating Characteristic) analysis. A total of 15 LPR patients (26.8%) of the clinical group met MII-pH diagnostic criteria. Among subjects classified as positive for MII- pH diagnoses, RSI and RFS mean scores were respectively 20 (SD ± 10.5) and 7.1 (SD ± 2.5), values not significantly different compared to the negative MII-pH group. The metric analysis of the items led to the realization of a binary recoding of the score. Both versions had similar psychometric properties, α was 0.840 for RSI original version and 0.836 for RSI binary version. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without LPR pathology diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for LPR pathology were ≥ 5 for RSI binary version and ≥ 15 for RSI original version. Both version overestimated LPR prevalence. The original version had more sensitivity and the RSI Binary version had more specificity. It would be necessary to think about modifying the original RSI in order to improve its sensitivity and specificity (RSI binary version, adding or changing some items), or to introduce new scores in order to better frame the probably affected of LPR patient.

Paraglottic and Pre-epiglottic Space Abscess in Adults: Report of Two Cases.

Introduction:Acute epiglottitis or supraglottitis is a rapidly progressing upper respiratory tract infection that can often threaten the airway patency. Epiglottic abscess that expands to the paraglottic (PGS) or preepiglottic (PES) space and acute airway obstruction constitute rare complications, exclusively presented in adults.Case Report:We report two cases. In the first case flexible fiberoptic Rhino-Pharyngo-Laryngoscopy showed epiglottitis that was obstructing the airway and abscesses on the lingual surface of the epiglottis. Abscesses were opened using laser CO2. In the following days flexible fiberoptic endoscopy revealed persisting protrusion of the left hemilarynx. A CT scan was performed showing an abscess in the paraglottic space. Under direct laryngoscopy the abscess was drained. In the second case endoscopic examination revealed epiglottitis that did not cause airway obstruction. The patient was admitted for follow-up and treated with intravenous antibiotics. On the 5th day showed an exacerbation of her symptoms. A CT scan was performed that showed the existence of an abscess in the preepiglottic space. She was taken to surgery and the abscesses were drained through a cervical- U shaped- incission.Conclusion:Existance of an abscess means, by default, an adequate surgical treatment to ensure the airway, and immediate drainage under direct laryngoscopy or through an external approach. Diagnosis is based exclusively on medical history and clinical examination. CT scan is necessary to reveal “secret” abscesses and “silent” extension of the infection inside pre-epiglottic and paraglottic space even if epiglottitis is mild. Postoperative management includes proper care of the surgical wound and antibiotics.

Role of ultrasound in evaluation of pharyngeal dysphagia in children with cerebral palsy

BackgroundThe aim of this study was to evaluate the clinical reliability of ultrasound (US) examination using relative laryngeal movement of 40% as a cutoff point to diagnose pharyngeal abnormalities of swallowing using ultrasonographic examination in dysphagic cerebral palsy (CP) patients and comparing its results with a flexible fiberoptic endoscope.MethodsTwenty-five cerebral palsy children suffering from clinical dysphagia were included in this study. The rest distance between the thyroid cartilage and the hyoid bone and the shortest distance between them during swallowing were measured by ultrasound, then the approximation distance and the percentage of relative laryngeal movement were calculated. All children also have been submitted for flexible fiberoptic endoscopy (FEES).ResultsThe mean value of the percentage of relative laryngeal movement was significantly less in the CP children with pharyngeal phase abnormality diagnosed by the flexible fiberoptic endoscope (p < 0.001). The mean of relative laryngeal movement in CP patients with and without pharyngeal abnormality diagnosed by the flexible fiberoptic endoscope was 20.10 ± 13.73 and 66.19% ± 3.42 respectively.ConclusionUltrasound can efficiently measure the relative laryngeal movement, and as it gives a numerical value, it can be used as a follow-up bedside test in children suffering from dysphagia.

Cannot intubate and cannot ventilate scenario in an infant for airway assessment.

Sir, Cannot intubate and cannot ventilate scenario, in general, is rare, especially in infant age group, but results in calamitous events if it occurs. Here, we report the management of a case of cannot intubate and cannot ventilate in an infant with a history of stridor. Case A 6-month-old girl was brought by an ambulance to our tertiary care hospital with difficulty in breathing and severe stridor. It was decided to perform airway assessment by ENT surgeon to determine the possible causes of stridor due to failure of improvement despite maximum medications given by pediatrician. Preoperative assessment showed an infant with mixed stridor requiring about 4 L of oxygen to maintain oxygen saturation above 90%. Suprasternal and intercostal recessions with conducted sounds could be heard on the chest. Chest X-ray was normal. No premedication was given and she was shifted to the operation theatre. Supraglottic airway assessment was done awake with topical anesthesia using flexible fiberoptic endoscope which was normal. Subglottic endoscopic examination was decided under general anesthesia. She was induced with sevoflurane to maintain spontaneous ventilation for dynamic airway assessment. The spontaneous ventilation was assisted with great difficulty after loss of consciousness. The ENT surgeon used pediatric rigid endoscope. It revealed subglottic mass occluding 90% of the area, and it was not possible to bypass the mass with the smallest endoscope available (size 2.7 mm) [Figure 1]. The infant started to desaturate after endoscopic manipulations with difficulty to ventilate. Intubation failed with the smallest tube size 2. Ventilation was tried but was not effective. The saturation and heart rate started to drop with the scenario of cannot intubate and cannot ventilate. Atropine was given and external cardiac massage started as saturation dropped to less than 50% and heart rate fell to less than 60 beats per minute. Emergency tracheostomy was done successfully in 7 min and saturation improved to 99%. Infant regained consciousness and spontaneous breathing. Computed tomography was done which revealed a small hypodense area measuring 0.5 cm in diameter in the region of glottis. LASER marsupialization of the subglottic cyst was done successfully after 2 days from emergency tracheostomy.Figure 1: Subglottic mass obstructing 90% of the airwayUnfortunately, there is no definitive algorithm to follow for difficult airway in case of patients aged less than 1 year of age. Difficult airway society (DAS) published algorithm of cannot intubate and cannot ventilate in a paralyzed anesthetized child aged 1–8 years in 2015.[1] In the present case, we skipped insertion of supraglottic devices, percutaneous transtracheal jet ventilation (PTJV), rigid bronchoscopy ventilation, and percutaneous cannula cricothyroidotomy (PCC) for different reasons. Supraglottic devices cannot be used due to distal mechanical obstruction. PTJV is relatively contraindicated due to near total airway obstruction below vocal cord.[2] In addition to risk of serious complications such as air embolism, extensive cervical emphysema, pneumothorax, and damage to the esophagus occur if jet ventilation is tried with misplaced cannula.[3] Rigid bronchoscopy ventilation was impossible as the smallest endoscope of size 2.7 mm could not bypass the mass. PCC is not easy in infants. Moreover, it is challenging to obtain a proper angle to insert PCC without the risk of perforation of posterior tracheal wall.[4] Emergent tracheostomy should be considered as the first step if an ENT surgeon is available.[5] The management of cannot intubate, cannot ventilate scenario needs vast experience in airway assessment, unshaken confidence, with extreme cooperation between anesthetists and ENT surgeons. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Evaluation of Vocal Fold Motion During Blocks in Adults Who Stutter

We used data obtained through flexible fiberoptic endoscopy and measurements of airflow and voice obtained from speech phonogram waveforms for 58 blocks in 12 AWS who were asked to read a set text for measurements. We compared the number of blocks with glottal closure and glottal opening during stuttering.

Endoscopic and Phoniatric Evaluation in Singing Students

In To analyze laryngostroboscopic findings and ENT/phoniatric examination results in a group of singing students and in a control group of non-singing subjects to emphasize the importance of ENT/phoniatric examination and of laryngostroboscopy before taking up singing. 56 singing students and 60 healthy euphonic non-singer volunteers were recruited. In each subject a perceptual assessment and a self-assessment (VHI) of the voice were performed. The singing students filled out the Singing-VHI. All subjects underwent flexible fiberoptic endoscopy and laryngostroboscopy. All subjects were evaluated through the Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS). At laryngostroboscopy, 60.7% of students presented pathological findings, versus 20% of controls (P < 0.0001). Incomplete glottic closure (35.7% vs. 13.3%), supraglottic hypertonus (16.1% vs. 5%), organic lesions (bilateral nodules, cysts, sulcus vergeture) (17.9% vs. 3.3%), posterior erythema (16.1% vs. 5%) and laryngeal edema (14.3% vs 3.3%) were more frequent in the students. The most common symptoms in singers were phonasthenia (37.5 % vs 6.7%; P = 0.0001) and mucus sensation (17.9% vs. 5%, P = 0.03). S-VHI showed higher values in students with pathological laryngostroboscopy (P < 0.0001). Finally, average RSI and RFS were higher in students. Due to the high percentage of organic and functional voice disorders in singing students, it would be desirable that every subject who is going to start singing underwent an ENT/phoniatric investigation with videostrobolaryngoscopy to ascertain vocal folds healthy condition.

Stroboscopy: an evolving tool for voice analysis in vocal cord pathologies

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Benign vocal fold disease, such as vocal polyp, vocal nodule, intracordal cyst or Reinke’s edema is one of the most common causes which deteriorate the voice. Since 1854 when Manuel Garcia first observed the movement of his own vocal cords using a laryngeal mirror and sunlight as the light source, a number of techniques for demonstrating laryngeal anatomy have evolved. Preoperative evaluation of these lesions initially by indirect laryngoscopy or direct rigid laryngoscopy, gave way to the use of transnasal flexible fibreoptic endoscopy in the eighties. The introduction of the video stroboscope into Otorhinolaryngology practice has revolutionized the assessment of vocal cord pathology.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The present study includes a 50 cases of subjects with complain of change of voice coming at department of E.N.T and Head and Neck surgery, at our hospital. A detailed history was taken following which a thorough examination of larynx using appropriate techniques were carried out. Further investigations were done as and when required. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; On stroboscopic examination patients were analyzed on four parameters like, symmetry, amplitude, periodicity and mucosal wave. Observations of periodicity and mucosal wave were significantly different in preoperative and post-operative analysis. Stroboscopic evaluation suggested that preoperatively 50% of the patient were having asymmetricity, decreased amplitude, aperiodicity and absent mucosal wave. On postoperative follow-up at 15 days and 2 months interval almost all the patients got all the parameters near normal.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; It was observed that statistical significant difference in pre and postoperative findings of different parameters of voice evaluated using it. We can draw the probable conclusion that video stroboscope proved to be useful and reliable tool for evaluation of the patients with benign vocal cord pathologies as it reflects the change in the all the parameters of voice postoperatively most accurately and promptly. &lt;/p&gt;