Flexible Laryngoscopy Research Articles

Management of Complex Airway Caused by Massive Retropharyngeal Goiter

Abstract Introduction: The patient is a 52-year-old male with massive retropharyngeal thyroid goiter causing compressive symptoms and a complex airway. This intraoperative video demonstrates simultaneous Glidescope exposure with flexible fiberoptic laryngoscopy utilizing the Seldinger technique to intubate. Materials and Methods: This is a single patient case presentation using pre and postoperative flexible fiberoptic nasopharyngoscopy and intraoperative Glidescope video. Results: Management of the complex airway with resolution of compressive symptoms after total thyroidectomy was effective. Conclusions: Simultaneous use of Glidescope for exposure with flexible fiberoptic laryngoscopy utilizing the Seldinger technique is a viable option for managing complex airways caused by massive retropharyngeal goiters. D.J.T. has been a speaker for Genzyme during the past 2 years. All other authors have no other potential conflicts to disclose. This case is to be presented on a panel at the World Congress on Thyroi...

Flexible Fiber-Optic High-Speed Imaging of Vocal Fold Vibration: A Preliminary Report

High-speed video (HSV) imaging of vocal fold vibration has been possible only through the rigid endoscope. This study reports that a fiberscope-based high-speed imaging system may allow HSV imaging of naturalistic voicing. Twenty-two subjects were recorded using a commercially available black and white high-speed camera (Photron Motion Tools, 256 × 120 pixel, 2000 frames per second, 8 second acquisition time). The camera gain is set to +6 db. The camera is coupled to a standard fiber-optic laryngoscope (Olympus ENF P-4) with a 300-W Xenon light. Image acquisition was done by asking the subject to perform repeated phonation at modal phonation. Video images were processed using commercial video editing and video noise reduction software (After effects, Magix, and Neat Video 4.1). After video processing, the video images were analyzed using digital kymography (DKG). The HSV black and white video acquired by the camera is gray and lacks contrast. By adjustment of image contrast, brightness, and gamma and using noise reduction software, the flexible laryngoscopy image can be converted to video image files suitable for DKG and waveform analysis. The increased noise still makes edge tracking for objective analysis difficult, but subjective analysis of DKG plot is possible. This is the first report of HSV acquisition in an unsedated patient using a fiberscope. Image enhancement and noise reduction can enhance the HSV to allow extraction of the digital kymogram. Further image enhancement may allow for objective analysis of the vibratory waveform.

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

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

Research progress of laryngomalacia in children

Laryngomalacia is defined as a supraglottic collapse of the glottis, resulting in intermittent airflow obstruction and associated wheezing. This disease is the most common cause of stridor in neonates and infants. Associated feeding difficulties are present in approximately half of the children. A definitive diagnosis can generally be made with flexible fiberoptic laryngoscopy. The disorder is most often self-limited with resolution of symptoms within the first 24 months of life, and the majority of children can thus be managed conservatively. The approximately 5%-20% of children with severe or refractory disease may require more aggressive intervention, most commonly in the form of transoral supraglottoplasty. High success rates and a low rate of complications have been reported for this procedure in otherwise healthy children. Children with syndromes or medical comorbidities are more likely to have complications or persistent symptoms after supraglottoplasty and may require additional interventions.

Evaluation of simple pre-determined length insertion technique (SPLIT) with conventional method for oral fibreoptic intubation: A randomised cross-over study

Background and Aims:The difficulty during flexible fiber-optic bronchoscopy (FOB) guided tracheal intubation could be because of inability in visualising glottis, advancing and railroading of endotracheal tube. Several methods are available for visualising glottis, but none is ideal. Hence, this randomised controlled study was designed to evaluate the simple pre-determined length insertion technique (SPLIT) during oral FOB.Methods:Fifty-eight patients were randomised into Group C and Group P. General anaesthesia was maintained with sevoflurane and oxygen in spontaneous respiration. In Group C, conventional flexible fiberoptic laryngoscopy was done followed by SPLIT and vice versa in Group P. The time to visualise the glottis (T1), from glottic visualisation to pass beyond glottis (T2) and from incisors to pass beyond the glottis (T3) were noted from the recorded video. The time interval was analysed using Wilcoxon matched pairs test and Mann–Whitney U-test.Results:The T1 was significantly less in SPLIT as compared to conventional technique (13 [10, 20.25] vs. 33 [22, 48] s). The T3 was significantly less in SPLIT (24.5 [19.75, 30] vs. 44 [34, 61.25] s). The T1 by SPLIT was comparable between residents and consultants (P = 0.09), whereas it was significantly more among residents than the conventional technique. The SPLIT was preferred by 91.3% anaesthesiologists.Conclusion:The SPLIT significantly lessened the time to visualise the glottis than conventional technique for FOB. The SPLIT was the preferred technique. Hence, we suggest using the SPLIT to secure the airway at the earliest and also as an alternative to conventional technique.

Subglottic widening using a rotated H-shaped cricotracheal split for composite nasal septal cartilage grafting

IntroductionVarious open surgical techniques have been previously described for subglottic stenosis. These techniques usually involve steroid injections, endoscopic dilatations, flaps, and placement of intraluminal stents. A retrospective review was conducted on 20 patients with subglottic stenosis who underwent surgical widening using composite nasal septal grafts utilizing a rotated H-shaped cricotracheal split and temporary tracheotomy without stenting. Tracheotomy was performed for patient safety. All patients maintained patent airways with wide subglottic area throughout the follow-up period. All of them were extubated or decannulated 28–33 days after surgery by removing the tracheostomy tubes. All patients started antireflux treatment on the first postoperative day and steroid inhalation 2 weeks after surgery, which was maintained for 3 months. No patients underwent further procedures. All 20 patients were decannulated and were doing well at the time of writing. To conclude, composite nasal septal cartilage grafts with a rotated H-shaped cricotracheal split for subglottic stenosis in selected cases is a viable and effective option.ContextThe most common sequel after reconstructive procedures may be restenosis of different degrees. Recurrent narrowing may be due to healing by marked fibrosis, which is a result of postoperative infection, perichondritis in the graft or recipient site, with resorption of the augmenting cartilage graft. Intraluminal stenting predisposes to infection, subperichondrial abscesses, and devitalization of the cartilage graft by friction and infection. Inadequate graft size, thickness, or method of fixation may be other factors for failure.AimThe aim of the study was to present the indications, surgical technique, and results of composite nasal septal cartilage grafts using a rotated H-shaped cricotracheal split for patients with subglottic stenosis.Patients and methodsThis is a retrospective review. A series of 20 patients who underwent composite nasal septal cartilage grafts without stenting from 2009 to 2014 were reviewed. They suffered from subglottic and upper tracheal stenosis: 13 patients had subglottic stenosis due to rhinolaryngeoscleroma (seven male and six female patients), five patients had postintubation upper tracheomalacia and stenosis (one male and four female patients), and two male children had congenital subglottic stenosis. Postoperative data included mortality and morbidity rate, success of decannulation, need for repeat tracheotomy or Montgomery T-tube placement, and number of additional airway procedures.ResultsThe operative time ranged from 1.5 to 3.25h with a mean of 2.2 h. Blood loss ranged from 85 to 290 cm3, with a mean of 150 cm3. Hospitalization was 3 days in all patients with discharge on the third postoperative day, except for two children with congenital subglottic stenosis who stayed for 1 week. There were no major complications. Wound infection in two patients around the tracheotomy tube was evident 10 days after surgery, which was well controlled by parentral antibiotic and local antiseptic measures. Chest infection was recorded in five patients as mild to moderate tracheobronchitis, which resolved 1 week after surgery, except for the case of a 53-year-old female patient who progressed to bronchopneumonia after discharge, which resolved after 10 days. Return to normal life activity or work was possible in all patients after 2–3 weeks; however, 14 patients preferred home stay until tube removal. Weaning started 4 weeks after surgery and was successful within 1 week in all patients except for the two children, whose tubes were removed after 2 weeks of gradual weaning. Five patients experienced mild shortness of breath shortly after extubation, which increased with effort. They received steroid inhalation two to three times a day for 2 weeks with improvement in symptoms. During the follow-up period all patients sustained normal breathing, except for seven scleroma patients who after 4–7 months complained of mild dyspnea, which increased slightly with effort and prevailed thereafter. Follow-up flexible laryngoscopy detected mild mucosal edema and little granulation tissue around the grafted area at the time of extubation. These granulations were more evident and encroached slightly on the airway in the five patients who suffered from mild dyspnea shortly after extubation and regressed markedly after 2 weeks of steroid inhalation. There was rapid mucosal healing of nasal septal mucosa and laryngeal mucosa, which was nearly complete at 6 weeks after surgery, with a markedly wide subglottic area. Later on, endoscopic examination detected mild lumen narrowing in seven scleroma patients who complained of mild dyspnea 4–7 months after surgery. These patients showed no more narrowing on endoscopic examination through their subsequent months of follow-up. No other new symptoms developed in the follow-up period. No patient needed further surgical intervention.ConclusionComposite nasal septal cartilage grafting with a rotated H-shaped cricotracheal split is a viable and successful option for selected cases of laryngotracheal stenosis. The use of a stent with its associated morbidities is avoided with this technique. No additional endoscopic or open procedures were needed in any of the cases; successful decannulation in less than 1 month could be achieved.

喉頭腺扁平上皮癌例

We report a very rare case of adenosquamous carcinoma of the larynx. A 74-year-old man complained of dyspnea for two weeks. An examination using a flexible laryngoscope revealed a larger tumor in the left arytenoid region. First, we performed a tracheotomy, and resected the large tumor. The histological diagnosis was adenocarcinoma. We diagnosed the tumor as an adenocarcinoma of the larynx (T2N1M0, Stage III) and performed a total laryngectomy in combination with a left radical neck dissection and a right modified radical neck dissection. Finally, the histological diagnosis of the tumor was adenosquamous carcinoma. As dysplasia was observed in positive margin of the region of the primary tumor, we additionally performed postoperative irradiation. The patient has not experienced a relapse for more than 5 years.

Utility of polysomnography in determination of laryngomalacia severity

ObjectiveTo examine the efficacy of polysomnography in determining the severity of laryngomalacia in pediatric patients. MethodsProspective cohort study. Pediatric patients referred to our pediatric otolaryngology department with a polysomnogram already performed for a presumptive diagnosis of laryngomalacia were enrolled in the study. Patients with concurrent airway lesions or neuromuscular disorders were excluded. Patients underwent history, physical exam, and flexible fiberoptic laryngoscopy. These results were used to calculate a total laryngomalacia severity score. Results25 pediatric patients (n = 25) with an average age of 3.9 months at time of initial evaluation met criteria for enrollment in our study. 100% of patients had obstructive sleep apnea by definition. 80% of these patients underwent supraglottoplasty. The average AHI of those who underwent surgery (57.26) was not significantly different in those who underwent surgery vs. those that did not (55.43) (p = 0.41). In comparison, the average laryngomalacia severity score based from history, physical exam and flexible laryngoscopy was significantly greater in the patients that required supraglottoplasty (11.16) vs. those who did not (5.33) (p = 0.03). In addition a higher laryngomalacia severity score was not correlated with a higher AHI (p = 0.81, r = 0.08, CI: −0.5197 to 0.6235). ConclusionIn our cohort, polysomnography was not useful in determining the severity of laryngomalacia, did not correlate with the clinical evaluation, and alone was not predictive of the patients that would require surgical intervention. History, physical exam, and endoscopic findings remain reliable predictors of disease severity and need for operative intervention.

The Effects of Thermal Softening of Double-Lumen Endobronchial Tubes on Postoperative Sore Throat, Hoarseness, and vocal Cord Injuries

Abstract Background It is well known that thermal softening of polyvinyl chloride tracheal tubes reduces nasal damage during nasotracheal intubation. We hypothesized that thermal softening of double-lumen endobronchial tubes (DLTs) may be effective for reducing airway injury. This randomized double-blind study was performed to investigate whether thermal softening of DLTs decreased postoperative sore throat, hoarseness or vocal cord injuries. Methods Patients (n+140) undergoing one lung anaesthesia were randomized into two groups (n+70 each) depending on whether the DLT was softened by warming or not before tracheal intubation. The DLTs were placed in warm saline [40(1)°C] in the thermal softening group or in room temperature saline in the control group for 10 min. The vocal cords were examined by using flexible laryngoscopy immediately after extubation. Sore throat and hoarseness were evaluated for three postoperative days. The primary outcomes were the incidence of sore throat, hoarseness, and vocal cord injuries. Results Sore throat and vocal cord injuries occurred less frequently in the thermal softening group than in the control group [14/70 vs 27/70, risk ratio (95% CI): 0.52 (0.30–0.90), P+0.025 for sore throat; 15/70 vs 27/70, risk ratio (95% CI): 0.56 (0.32–0.95), P+0.042 for vocal cord injuries]. However, the incidence of hoarseness was comparable between the two groups. Conclusion Tracheal intubation with DLTs softened by warming decreased the postoperative incidence of sore throat and vocal cord injuries. Therefore, thermal softening of DLTs before intubation seems to be helpful in reducing airway injuries associated with DLT intubation. Clinical trial registration NCT 01626365.

Medialization Thyroplasty Using the Pocket and Silicone Implant Technique

Objective: To describe a new method of medialization thyroplasty using a modified preformed nasal silicone implant.
 Methods: 
 Design: Surgical Innovation
 Setting: Tertiary Private Hospital
 Participants: Four patients underwent medialization thyroplasty using a pocket and nasal implant technique performed by the senior co-author. The indication for medialization thyroplasty for these patients was hoarseness secondary to unilateral vocal fold paralysis of more than 6 months duration, and documented by flexible fiberoptic laryngoscopy. The outcomes were described with comparison of pre- and post-operative subjective voice assessment.
 Results: Operative time was 15–30 minutes. Post-operative subjective improvement of voice quality was evident. Scars were minimal and aesthetically acceptable. The procedure could be done on an outpatient basis. 
 Conclusion: Medialization thyroplasty via a pocket and silicone implant technique is initially effective and may be a worthwhile alternative to the usual window technique.
 Keywords: unilateral vocal cord paralysis; medialization thyroplasty; Isshiki thyroplasty; silicone implant

A 15-Year Occult Foreign Body in the Subglottic Area of A 50-Year-Old Woman

Objective:
 To present a case of subglottic foreign body (FB) impaction in a 50-year-old woman diagnosed with bronchial asthma for 15 years.
 Methods:
 Design: Case Report
 Setting: Tertiary Public Hospital
 Patient: One
 Results: A 50-year-old woman with recurrent cough and dyspnea for 15 years that had been managed as bronchial asthma, developed stridor and halitosis in the last 5 years. Flexible laryngoscopy revealed a subglottic mass and CT scan confirmed a suspicious foreign body in the lumen of the subglottis. Signs and symptoms resolved after peroral endoscopic removal of the foreign body from the larynx. Histopathology of the extracted material from the airway confirmed it to be “bone tissue.”
 Conclusion: Foreign body aspiration can occur in adults without predisposing factors. Its diagnosis can be challenging as it can mimic respiratory disorders such as bronchial asthma. Endoscopy and computed tomography are valuable for correct diagnosis and management. An incorrect initial diagnosis should be considered in the light of unresolved symptoms and prompt referral to an appropriate specialist may prevent undue suffering and dangerous complications.
 Keywords: foreign body aspiration, occult airway foreign body

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

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

Recurrent squamous cell carcinoma involving cranial nerves in a patient with left glottic carcinoma treated with definitive radiation therapy: A case report

Practical Radiation Oncology (2017) 7, 100-102 www.practicalradonc.org Teaching Case Recurrent squamous cell carcinoma involving cranial nerves in a patient with left glottic carcinoma treated with definitive radiation therapy: A case report Kunal Sindhu BA a , William Armstrong MD b , Anton Hasso MD c , Ted Farzaneh MD d , Parima Daroui MD, PhD e, ⁎ a Warren Alpert School of Medicine, Brown University, Providence, Rhode Island Department of Otolaryngology, Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California c Department of Radiology, Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California d Department of Pathology, Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California e Department of Radiation Oncology, Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California b Received 19 September 2016; revised 4 November 2016; accepted 10 November 2016 Introduction Side effects from definitive radiation therapy in patients with cancers of the head and neck are not uncommon. Controlling the acute side effects of treatment, including mucositis, xerostomia, dysphagia, and dysphonia, is of the utmost necessity because these symptoms are potentially debilitating and may jeopardize patients’ adherence to treatment regimens. In the longer term, persistent xeros- tomia, difficulties with speech and swallowing, and fibrosis have been noted in patients who have received radiation therapy. 1 Radiation-induced cranial neuritis, although rare, has also been observed and most often affects the sixth and twelfth cranial nerves. 2 When patients with a history of head or neck radiation treatment develop these symptoms, however, clinicians must maintain a wide differential diagnosis because each of these symptoms has a vast array of potential etiologies. In this report, we present a patient whose symptoms, although mirroring Conflicts of interest: None. ⁎ Corresponding author. Department of Radiation Oncology, University of California Irvine, 101 The City Drive South, Building 23, Orange, CA 92868. E-mail address: pdaroui@uci.edu (P. Daroui). some of those known to be long-term consequences of radiation therapy, were instead found to be a manifestation of a recurrence of squamous cell carcinoma (SCC) limited to the cranial nerve tract. Case report A 53-year-old man with a 50 pack-year smoking history initially presented to his primary care physician with nasal congestion and otalgia. Two months later, after antibiotics failed to ameliorate these symptoms, he developed progressive hoarseness and throat discomfort. Flexible fiberoptic laryngoscopy (FFL) performed by a specialist revealed an exophytic, left true vocal cord lesion. The patient was then referred to our institution, where a repeat FFL showed mucosal irregularity of the left true vocal cord in the context of otherwise symmetrically mobile vocal cords. Computed tomography scans of the neck demonstrated irregularity and thickening of the left true vocal cord with obscuration of the laryngeal ventricle. Microdirect laryngoscopy with partial excision of the left true vocal cord mass was performed to acquire tissue. A 10-mm mass along the superior surface of the left true http://dx.doi.org/10.1016/j.prro.2016.11.004 1879-8500/© 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Laryngeal Injury and Pneumomediastinum Due to Minor Blunt Neck Trauma: Case Report

BackgroundSerious isolated laryngeal injuries are uncommon in children. Case ReportWe describe the case of an 8-year-old boy with laryngeal injury and pneumomediastinum due to minor blunt neck trauma. He presented to the emergency department complaining of odynophagia and hoarseness, but without respiratory distress. Emphysema was seen between the trachea and vertebral body on initial cervical spine x-ray study, and flexible laryngoscopy revealed erythema and mild edema of both the right vocal cord and the arytenoid region. He recovered with conservative management only. Why Should an Emergency Physician Be Aware of This?We conclude that it is important to recognize subtle evidence of laryngeal injury secondary to blunt neck trauma to ensure early diagnosis. Initial cervical spine x-ray assessment should exclude both cervical spine fracture and local emphysema after blunt neck trauma. If patients with blunt neck trauma have evidence of a pneumomediastinum, the clinician should consider the possibility of aerodigestive injury.

Evaluation of Vocal Fold Motion Abnormalities: Are We All Seeing the Same Thing?

Flexible laryngoscopy is the principle tool for the evaluation of vocal fold motion. As of yet, no consistent, unified outcome metric has been developed for vocal fold paralysis/immobility research. The goal of this study was to evaluate vocal fold motion assessment (inter- and intra-rater reliability) among general otolaryngologists and fellowship-trained laryngologists. Prospective video perceptual analysis study. Flexible laryngoscopic examinations, with sound, of 15 unique patient cases (20 seconds each) were sent to 10 general otolaryngologists and 10 fellowship-trained laryngologists blinded to clinical history. Reviewers were given written definitions of vocal fold mobility and immobility and two video examples. The cases included bilateral vocal fold mobility (six), unilateral vocal fold immobility (five), and unilateral vocal fold hypomobility (four). Five examinations were repeated to determine intra-rater reliability. Participants were asked to judge if there was or there was no purposeful motion, as described by written definitions, for each vocal fold (800 tokens in total). Twenty reviewers (100%) replied. Both general otolaryngologists and fellowship-trained laryngologists had an overall inter-rater reliability of 95%. Difference in inter-rater reliability between the two groups of raters was negligible: 95% for general otolaryngologists and 97.5% for fellowship-trained laryngologists. There was no variability in intra-rater reliability within either rater group (99%). Intra- and inter-rater agreement in determining whether the patient had purposeful vocal fold motion on flexible laryngoscopic examination was excellent in both groups. This study demonstrates that otolaryngologists can consistently and accurately judge the presence and the absence of vocal fold motion.

A Case of Rare but Lethal Paraquat Toxicity

Introduction: Patients with corrosive ingestion usually present with upper gastrointestinal or airway complaints. Clinical knowledge of severity of tissue injury from corrosive agents, duration of contact, the amount and state (liquid or solid) of the substance involved, is necessary. We present a fatal case of odynophagia after accidental ingestion of a small amount of paraquat, leading to death after 10 days. Case: A 91 year old male with history of hypertension presented one hour after accidental ingestion of 1-2 teaspoons of paraquat, a potent weed killer. He immediately spit it out but had ingested small amount, less than 10cc. Initially, he was asymptomatic except burning sensation of the mouth and throat. His tongue was coated and erythematous. Flexible laryngoscopy on arrival was normal except for posterior oropharyngeal erythema. He could tolerate clear liquids. His initial labs were unchanged from baseline. CT neck and thorax revealed mild thickening of the proximal esophagus with no evidence of pneumomediastinum or pneumothorax. Proximal esophageal injury due to a corrosive substance was suspected. Endoscopic work up was held due to high risk of esophageal perforation. After 48hr of admission, he developed odynophagia with his own saliva. Renal function gradually worsened with creatinine increasing from 1.1 to 6.7mg/dl. Initial chest x-ray showed mild congestive changes that progressively worsened to bilateral bibasilar opacities during hospitalization leading to hypoxic respiratory failure. He showed some improvement in his swallowing capacity and was started on clear liquid diet but developed multiorgan failure, which was the cause of his death. Discussion: Paraquat is a rapidly absorbable bipyridyl compound which gets concentrated inside cells, where it undergoes redox cycling leading to free radical induced injury over a period of hours to days. Swallowing more than 30 mL of 20 to 24% paraquat concentrate is usually lethal, and as little as 10 mL can cause significant illness. Factors linked to worse outcomes are history of kidney disease and age over 50 years. Treatment is supportive with close monitoring. Oxygen supplementation should be avoided as it facilitates free radical formation. There is insufficient evidence to support use of antioxidants. Endoscopy in such patients should be avoided or delayed because of high risk of perforation and mortality rate.Figure 1Figure 2

An Elusive Fishbone: The Role for Repeat Imaging and Rigid Endoscopy

Accidental ingestion of fish bones with fear of oropharyngeal or esophageal impaction is a common emergency room presentation. Only 20-30% of patients, however, will have a confirmed retained fish bone. Sharp objects in the esophagus are a medical emergency given the risks of potentially fatal complications to include esophageal perforation, bacteremia, abscess and esophageal-aortic or tracheoesophageal fistula formation. Radiographic studies are recommended to localize foreign bodies as well as to evaluate for signs of perforation. We present a 50-year-old female with CT images confirming a fish bone impacted in the cervical esophagus despite normal flexible endoscopy. Our aim is to highlight the elusive nature of impacted fish bones and their appropriate management. A 50-year-old female with history of anxiety and dysphagia, presents with a suspected retained fishbone and odynophagia. She had a normal EGD one year prior to presentation. The patient was uncomfortable and drooling with a persistent foreign body sensation. An oral exam did not reveal any foreign bodies. A CT scan confirmed a 2.7cm linear density with a punctate focus of air. Otolaryngology performed a flexible laryngoscopy but did not identify the bone or any signs of trauma. Gastroenterology was then consulted for an EGD which was unremarkable. A repeat CT scan confirmed the bone had not passed and was still in the proximal esophagus. Rigid endoscopy was subsequently performed with successful removal of a 2.7 cm fish bone buried in the right posterolateral cervical esophageal wall. The patient was admitted, started on prophylactic antibiotics, and was discharged home the next day without complications. The majority of fish bones will become lodged in the oropharynx, posterior tongue, pyriform sinuses or cervical esophagus. Traditionally, impactions in the cervical esophagus and oropharynx can be removed with flexible endoscopy. Our case demonstrates the value of repeat imaging and potentially rigid endoscopy when flexible endoscopy fails to localize or remove a foreign body. Given the elusive nature of fish bones and the significant potential complications of this condition, providers should maintain a high index of suspicion even with negative flexible endoscopy.Figure 1Figure 2Figure 3

Hoarseness of voice – an institutional study

<p class="abstract"><strong>Background:</strong> Hoarseness is one of the earliest signal of local and systemic disease. It should be emphasized that hoarseness is not a disease in itself but a symptom of disease or disturbance of larynx or laryngeal innervation. The aim of the study was to analyse various causes and conditions associated with hoarseness of voice.</p><p class="abstract"><strong>Methods:</strong> We studied 150 patients in a prospective randomised study with inclusion criteria of hoarseness of voice, attending otolaryngology outpatient department of Dayanand medical college and hospital, Ludhiana, irrespective of their age, sex and duration of disease. No exclusion criteria were applied. All the routine investigations like Hb, BT, CT, TLC, DLC, urine-for albumin and sugar were carried out in all patients. X-ray chest- PA view and X-Ray soft tissue neck- AP and lateral view were done when required. Larynx was examined by flexible fibreoptic laryngoscopy followed by biopsy if suspicious looking area was seen. 4% lignocaine spray was used orally and nasally to provide local anaesthesia.</p><p class="abstract"><strong>Results:</strong> In the present study of 150 cases 87 were males and 63 were females with M:F ratio of 1.4:1 and age ranged from 10–90 years with majority of cases in 4th and 6th decade of their life. All patients had history of hoarseness of voice with most of patients having duration of disease between one month to one year. On flexible fibreoptic laryngoscopy 27% of cases showed normal study, vocal nodule was most common, seen in 20% of cases, 10% showed vocal cord palsy and 10% had laryngopharyngeal reflux disease. Bilateral lesion (72.6%) predominated overall, with left sided (15.2%) of larynx affected more as compared to right side (12%).</p><p><strong>Conclusions:</strong> Flexible fibreoptic laryngoscopy is an effective alternative for diagnosis of laryngeal lesions and various causes of hoarseness of voice. Vocal nodule has been found as the commonest cause of hoarseness of voice followed by vocal cord palsy and laryngopharyngeal reflux disease. </p>

Exercise-induced inspiratory symptoms in school children.

Exercise-induced inspiratory symptoms (EIIS) have multiple causes, one of which is exercise-induced laryngeal obstruction (EILO). There is limited knowledge regarding EIIS in children, both in primary care practices and in pediatric asthma clinics. The aim of this study was to describe the feasibility of a diagnostic methodology and its results in a cohort of children with EIIS referred to our tertiary pediatric pulmonary center. This study analyzed consecutively collected data in children from East Denmark and Greater Copenhagen referred during a 3½ years period. The continuous laryngoscopy exercise (CLE) test directly visualizes the larynx using a flexible laryngoscope during a maximal exercise test. A post-test questionnaire evaluated the subjective impact of the examination. The study included 60 children (37 girls/23 boys) with a mean age of 14 years (range 9-18). The feasibility of the CLE test was 98%; 18 children (35%) had EILO, while 33 children (61%) showed no abnormalities. Other laryngeal abnormalities were observed in three children before the exercise test. Asthma medication was successfully discontinued in 13 (72%) children with EILO. A significantly greater proportion of children shown to have EILO in the CLE test reported coping better with their EIIS than children with negative test (85% vs. 45%; P = 0.03). Continuous laryngoscopy during exercise is feasible and useful for identifying children with EILO. A correct diagnosis of EILO can help relieve patient anxiety, improve their coping with symptoms, and prevent unnecessary long-term and potentially harmful asthma treatments involving high-dose inhaled steroids. Pediatr Pulmonol. 2016;51:1200-1205. © 2016 Wiley Periodicals, Inc.

Preliminary application of Dx-pH monitoring system in laryngopharyngeal reflux disease

Objective: To summarize the application and significance of Dx-pH monitoring system in laryngopharyngeal reflux disease. Methods: Fifty-four patients who had symptoms of laryngopharyngeal reflux disease in our department from February to December in 2015 were retrospectively analyzed in this study. All patients were evaluated with reflux symptoms index(RSI), flexible laryngoscope and reflux finding score(RFS), and larygopharygeal Dx-pH monitoring. Results: Among all 54 patients, there were 26 patients whose Ryan score were positive(48.2%). The positive Ryan score mainly emerged when the patients were upright(24/26, 92.3%). Among 22 patients whose symptoms could not alleviate well by 8 weeks proton pump inhibitors treatment, there were 13 patients(59.1%) with positive Ryan scores. The Ryan scores were not in good accordance with RSI and RFS(κ=-0.013). Conclusions: Although the results were not in good accordance with RSI/RFS, Dx-pH monitoring system could prove laryngopharyngeal reflux events in patients with laryngopharyngeal reflux disease and help physicians to diagnose.