Laryngeal Examination Research Articles

Atypical carcinoid of larynx and management using transoral robotic surgery: Supraglottic laryngectomy

Atypical carcinoid tumor of the larynx is a particularly rare occurrence. Here, we report a patient with a laryngeal neuroendocrine tumor (NET) who was treated with transoral robotic surgery-supraglottic laryngectomy (TORS-SL). A 73-year-old male patient, a known smoker, presented with throat pain and hoarseness for 1 month. Endoscopic laryngeal examination and magnetic resonance imaging revealed a left supraglottic mass. The results of histopathologic examination and immunohistochemical analysis were consistent with atypical carcinoid tumor of the larynx. A TORS-SL was performed. There was no recurrence during a follow-up period of 18 months. NETs of the larynx are a very heterogeneous group of tumors in terms of pathological features and biological behavior. The histological diagnosis is the most important step in the management of these tumors. Tumor histology is an important determinant of prognosis. TORS-SL is a promising, minimally invasive, endoscopic surgical alternative for the treatment of supraglottic tumors with good functional and clinical outcomes as seen in this case.

A nasal mass discovered during intubation. Schwannoma.

Aman in his 50s presented with a 3-month history of right-sided nasal obstruction secondary to nasal trauma sustainedduring intubation for coronary artery bypass graft surgery. He reported postnasal drip, anosmia, and rhinorrhea. Nasal endoscopy revealed a large, right-sidedpolyp that extended into theposterior choana, indenting the rightpostero-inferior nasal cavity. The remainderof the nasopharyngeal, oropharyngeal, and laryngeal examination findings were unremarkable. Magnetic resonance imaging (MRI) showedawell-definedsofttissuemass,heterogeneous insignalonT2-weightedslices, andwith smooth bone remodeling (Figure, A). Owing to a reported history of a reaction to administration of gadolinium, contrast was not administeredduringMRI acquisition. Therewasnoevidenceof extension beyond the nasal cavity. Thepatientwas taken to theoperating roomfor abiopsyof this mass. Nasal endoscopy revealed a large pedunculated mass originating from the right middle turbinate. It was excised at its stalk at the lateral aspect of the axilla of the rightmiddle turbinate. Grossly, it was firm, rubbery, and heterogeneous in texture. Intraoperative frozen sections showed spindle cell morphologic characteristics. Later, the sections showedstrong staining characteristics for S-100. What is your diagnosis? A

Vascular lesions of vocal folds--part 1: horizontal vascular lesions

In recent decades, the endoscopic methods and technologies for laryngeal examination have improved so much that not only epithelial changes, but also vascular changes are recognizable at earlier stages. When comparing newer and older literature, the associated increasingly differentiated descriptions of such visible vascular changes of the vocal folds lead to terminological blurring and shifts of meaning. This complicates the technical-scientific discourse. The aim of the present work is a theoretical and conceptual clarification of early vascular changes of vocal folds. Horizontal changes of benigne vascular diseases, e. g. vessel ectasia, meander, increasing number and branching of vessels, change of direction may develop in to manifest vascular lesions, like varicosis, polyps and in case of ruptures to haemorrhages of vocal folds. These beginning and reversible vascular changes, when early detected and discussed basing on etiological knowledge, may lead to more differentiated prognostic statements and adequate therapeutic decisions, e. g. phonosurgery, functional voice therapy, voice hygiene and voice rest. Vertical vascular changes, like vessel loops, occur primarily in laryngeal papilloma, pre-cancerous and cancerous changes of the vocal folds. Already in small cancerous lesions of the vocal folds the vascular architecture is completely destroyed.

Differential diagnosis in paradoxical vocal fold movement (PVFM): An interdisciplinary task

ObjectivesThe objective of this study was to contribute to the discussion of differential diagnosis in paradoxical vocal fold movement (PVFM), a disorder frequently associated with episodes of breathing difficulty and stridor. Because of analogous respiratory symptoms, PVFM is often misdiagnosed as asthma. Additional evidence suggests the association of factors such as respiratory struggle during physical exertion, digestive reflux, and respiratory allergies with PVFM, particularly in athletes and young females. Interdisciplinary attention is warranted to avoid unnecessary utilization of medical resources and potential delay in the application of proper treatment. MethodsA description of critical points in PVFM differential diagnosis is proposed, featuring the assessment of a seven-year-old female with a history of behaviors considered to exacerbate voice fatigue symptoms. Noticeably, the child has consistently demonstrated tiredness and respiratory difficulties during physical education classes. Past use of oral steroids to reduce respiratory problems was applied with no improvement; short-acting beta 2-agonists have been also tried with mild improvement. Indications of instability and effort associated with respiratory–phonatory functions were demonstrated.Furthermore, there was evidence of GERD and seasonal allergies. ResultsThe literature suggests an association of factors such as respiratory struggle during physical exertion, unwanted vocal effort, GERD, and respiratory allergies in individuals with PVFM, particularly in young females. A diagnosis of PVFM was suggested, in association with paradoxical vocal folds motion caused by respiratory difficulties verified by laryngeal examination. ConclusionsIn PVFM, the vocal folds adduct during inhalation, thereby restricting the airway opening. Inconsistent vocal folds movement during phonation may also lead to PVFM symptoms. Acute bronchospasm/asthma-like symptoms, as well as additional morbidity may impact accuracy of diagnosis, leading to unnecessary use of asthma medications and office/emergency room consultations.

Narrow Band Imaging: Demonstration of Laryngeal Micro‐vascularization in Normal and Pathological Conditions

Objectives: With blue and green light only, narrow band imaging (NBI) allows better visualization of mucosal micro-vascular architecture. Intra-epithelial papillary capillary loops (IPCL) is a classification of vascular patterns based on previous esophageal NBI studies. The aims of the study were to: (1) Study the normal micro-vascular anatomy of the larynx by means of NBI. (2) Better understand the clinical applications of NBI in laryngeal lesions. (3) Assess the relative advantages and disadvantages of NBI versus white light imaging in the larynx. (4) Assess the relevance of previously described IPCL classification in laryngeal pathologies. Methods: A prospective comparative study including patients who arrived for laryngeal examination at an ENT referral center in 2013. White light images and NBI were compared in each patient to assess relative advantages of each modality. Micro-vascular architecture was described by IPCL classification. Results: A total of 110 patients were included and underwent video-stroboscopy, flexible distal-chip endoscopy, and NBI of the larynx. Thirty-two patients had a normal larynx, 54 had benign conditions, and 24 had malignant lesions. Distinct characteristics of vascular patterns were visualized by NBI in normal tissues, as well as a wide spectrum of benign and malignant conditions. In several patients with malignant and premalignant conditions, NBI revealed more extended disease than what was observed by white light imaging. Conclusions: Using NBI along with white light imaging, while understanding the unique microvascular fingerprint of each laryngeal pathologic condition, can assist the physician in differential diagnosis. In specific conditions, including malignant and premalignant lesions, NBI can bring better assessment of lesions’ size and extension.

Laryngoscopic and Spectral Analysis of Laryngeal and Pharyngeal Configuration in Non-Classical Singing Styles

The present study aimed to assess three different singing styles (pop, rock, and jazz) with laryngoscopic, acoustic, and perceptual analysis in healthy singers at different loudness levels. Special emphasis was given to the degree of anterior-posterior (A-P) laryngeal compression, medial laryngeal compression, vertical laryngeal position (VLP), and pharyngeal compression. Prospective study. Twelve female trained singers with at least 5years of voice training and absence of any voice pathology were included. Flexible and rigid laryngeal endoscopic examinations were performed. Voice recording was also carried out. Four blinded judges were asked to assess laryngoscopic and auditory perceptual variables using a visual analog scale. All laryngoscopic parameters showed significant differences for all singing styles. Rock showed the greatest degree for all of them. Overall A-P laryngeal compression scores demonstrated significantly higher values than overall medial compression and VLP. High loudness level produced the highest degree of A-P compression, medial compression, pharyngeal compression, and the lowest VLP for all singing styles. Additionally, rock demonstrated the highest values for alpha ratio (less steep spectral slope), L1-L0 ratio (more glottal adduction), and Leq (more vocal intensity). Statistically significant differences between the three loudness levels were also found for these acoustic parameters. Rock singing seems to be the style with the highest degree of both laryngeal and pharyngeal activity in healthy singers. Although, supraglottic activity during singing could be labeled as hyperfunctional vocal behavior, it may not necessarily be harmful, but a strategy to avoid vocal fold damage.

Associations between laryngeal and cough dysfunction in motor neuron disease with bulbar involvement.

True vocal fold (TVF) dysfunction may lead to cough ineffectiveness. In individuals with motor neuron disease (MND), cough impairment in the context of dysphagia increases risk for aspiration and respiratory failure. This study characterizes differences and associations between TVF kinematics and airflow during cough in individuals with bulbar MND. Sequential glottal angles associated with TVF movements during volitional cough were analyzed from laryngeal video endoscopy examinations of adults with bulbar MND (n = 12) and healthy controls (n = 12) and compared with simultaneously collected cough-related airflow measures. Significant group differences were observed with airflow and TVF measures: volume acceleration (p ≤ 0.001) and post-compression abduction TVF angle average velocity (p = 0.002) were lower and expiratory phase rise time (p = 0.001) was higher in the MND group. Reductions in maximum TVF angle during post-compression abduction in the MND group approached significance (p = 0.09). All subjects demonstrated complete TVF and supraglottic closure during the compression phase of cough, except for incomplete supraglottic closure in 2/12 MND participants. A strong positive relationship between post-compression maximum TVF abduction angle and peak expiratory cough flow was observed in the MND group, though it was not statistically significant (r = 0.55; p = 0.098). Reductions in the speed and extent of TVF abduction are seen during the expulsion phase of cough in individuals with MND. This may contribute to cough impairment and morbidity.

Does perioperative dexamethasone affect voice-related quality of life after thyroidectomy?

The objective of this study is to assess the impact of perioperative dexamethasone on post-thyroidectomy voice outcomes. This study is a retrospective review of prospectively collected data in a tertiary referral center. This is a retrospective analysis of prospectively collected data on adult patients undergoing total thyroidectomy. Exclusion criteria were: previous neck surgery, thyroid lobectomy, neck dissection or other procedure together with thyroidectomy, pathological findings on laryngeal examination, preoperative or postoperative steroid therapy, diabetes mellitus, pregnancy, and postoperative recurrent laryngeal nerve palsy. In all patients, flexible laryngoscopy was performed and Voice Handicap Index (VHI) scores were obtained the day before, 48 h and 1 month after surgery. Patients' medical records were reviewed to find the patients who had received dexamethasone by the anesthesiologist as nausea and vomiting prophylaxis or analgesia. Thus, two groups of patients were formed: dexamethasone (D) group and non-steroid (NS) group. Mann-Whitney test used to compare VHI between the two groups. 122 patients fulfilled the criteria. D group consisted of 50 patients (44 females; mean age 53.16 ± 17.61), in which a single IV dose of 8 mg dexamethasone had been administered perioperative, and NS group consisted of 72 patients (58 females; mean age 50.53 ± 13.60), where no steroids had been administered. No significant difference was noticed between D and NS groups for preoperative VHI score, VHI scores 48 h and 1 month after surgery. In our study, a single perioperative IV dose of 8 mg dexamethasone did not seem to add any benefit on voice-related quality of life after thyroid surgery.

Effect of Weight Loss on Voice After Bariatric Surgery

To investigate the effect of weight loss on voice. Prospective study. A total of 15 subjects undergoing bariatric surgery were investigated. Six subjects were lost to follow-up, and nine subjects were evaluated preoperatively and 3-6months postoperatively. The evaluation included a questionnaire on voice quality filled by the patient, laryngeal examination, perceptual evaluation, and acoustic analysis. The questionnaire consisted of four questions: change in vocal pitch, change in vocal loudness, increase or decrease in phonatory effort, and the presence or absence of vocal fatigue. For the perceptual evaluation, a simplified version of the Grade, Roughness, Breathiness, Asthenia, Strain scale classification was used. These parameters were rated using a score ranging from zero to three where zero stands for none and three for severe. For the acoustic analysis, the following variables were measured: fundamental frequency, habitual pitch, jitter, shimmer, noise-to-harmonics ratio, voice turbulence index, and maximum phonation time. The mean age was 35.56±9.93years. The mean weight preoperatively and postoperatively was 112.17 and 83.61kg, respectively. The body mass index dropped by eight points from 38.06 to 30.83. Only three of the nine patients have reported change in voice quality. The latter was described as an increase in vocal pitch in the three cases, reduced loudness and increased phonatory effort in two, and the presence of vocal fatigue in one. There was no significant difference in the mean score of any of the perceptual parameters in patients preoperatively versus postoperatively. There was also no significant difference in any of the acoustic parameters or in the laryngeal findings before and after surgery. One-third of the patients with weight loss reported change in voice quality that was not documented acoustically. The laryngeal examination is nonrevealing.

Hoarseness Misattributed to Reflux

This study aimed to identify voice disorders commonly misidentified as reflux and sources of such misattribution. Retrospective chart review. Twenty-six patients carrying a diagnosis of reflux alone presenting for second-opinion evaluation were identified from among 381 new patients presenting with a chief complaint of hoarseness over an 8-month period. Patients specifically referred for further workup were excluded. Average duration of reflux treatment was 10.6 +/- 9.0 weeks. In no case was reflux alone the cause of hoarseness. Eleven (42%) had phonotraumatic lesions, 9 (34%) had neurologic disorders, 5 (19%) had age-related changes, and I (4%) was infectious. Twenty-two (85%) abnormalities were diagnosed by dynamic laryngeal examination with improved optics, including stroboscopy. Only 4 (15%) represented disorders routinely diagnosed with flexible fiberoptic laryngoscopy. Hoarse patients with no apparent cause for dysphonia other than reflux after flexible laryngoscopy, or who fail to improve with appropriate treatment, may benefit from further laryngeal investigation rather than continued empiric treatment or further reflux evaluation.

Paralysies laryngées unilatérales de l’adulte : épidémiologie, symptomatologie, physiopathologie et traitement

In France, the main causes for unilateral laryngeal nerve paralysis in the adult patient are surgery and malignant tumors. Most of unilateral laryngeal nerve paralysis following thyroid surgery will recover within the first six postoperative months. At the time of unilateral laryngeal nerve paralysis, swallowing impairment and dyspnea occur in around 30% and 5% of cases, respectively. In the face of a unilateral laryngeal nerve paralysis occurring without a history of trauma of surgery, the main paraclinical examination to perform is a computed laryngeal nerve examination analyzing the whole length of the nerve involved. Speech therapy efficiency is related to the degree of severity of the symptoms related to unilateral laryngeal nerve paralysis. In the vast majority of cases, laryngeal medialization approaches improve dysphonia and swallowing impairment related to unilateral laryngeal paralysis, but not dyspnea.

Displacement of Residual Gore‐Tex Thyroplasty Implant Presenting as a True Vocal Fold Mass

Objectives:Describe the unique presentation and management of a patient with an ipsilateral true vocal fold mass following revision thyroplasty that was identified to have migration of residual Gore-Tex thyroplasty implant into the superficial lamina propria of the anterior true vocal fold.Methods:A single case of a patient who underwent revision type I thyroplasty after an unsuccessful attempt elsewhere using a Gore-Tex implant is reported. At the time of revision surgery, it was thought that all prior implant material was extricated, and the patient underwent revision type I thyroplasty using a carved silastic Netterville Implant with arytenoid adduction.Results:After initial improvement following the revision type I thyroplasty, the patient experienced deterioration of her voice. Indirect laryngeal examination revealed fullness on the superior surface of the right true vocal fold affecting mucosal wave and glottic closure. Microdirect laryngoscopy with endoscopic evaluation revealed migration of residu...

Laryngeal Carcinoma with Chronic Lymphocyter Leukemia

In this study, we report an extraordinary case in which a patient was diagnosed with laryngeal squamous cell carcinoma and simultaneous chronic lymphocytic leukemia. A 53-year-old male patient presented with hoarseness and a neck mass. Laryngeal examination revealed a lesion that had infiltrated the right band, cord, and ventricle, and the left cord and band. There were multiple bilateral lymphadenopathies in the supraclavicular, inguinal, and axillary regions, the largest of which was 4x4 cm. Following hematology consultation, a direct laryngoscopy and biopsy were performed. An excisional biopsy was taken from the neck mass. The postoperative histopathology reported an invasive squamous cell carcinoma in the larynx and a small B cell lymphoid leukemia in the neck. Following consultation with our oncology department, curative radiotherapy was applied to the neck region. Following this therapy, the mass was no longer detectable upon palpation, although no curative treatment was applied for leukemia. It is important to be aware that lymphadenopathy may be secondary to head or neck cancer or to a hematological malignancy. Thus, preoperative evaluation should be carefully performed, and hematological malignancy should be considered as a differential diagnosis when histopathologically evaluating neck dissection material.

Comparison of Propofol and Propofol/Ketamine Anesthesia for Evaluation of Laryngeal Function in Healthy Dogs

Thiopental is an excellent choice for evaluation of laryngeal function. Unfortunately, thiopental is no longer manufactured. In its absence, the ideal anesthetic protocol for laryngoscopy has not been determined. Propofol and propofol/ketamine were compared for the evaluation of laryngeal function in 48 healthy dogs. Laryngeal exposure was moderate to excellent in all dogs and not significantly different between protocols. Saturation of peripheral O2 (SPO2) readings were decreased in the propofol/ketamine group, and deeper respirations were more likely to correlate with normal laryngeal function regardless of treatment group. Doxapram was administered to apneic patients to stimulate respiration and allow for evaluation of laryngeal function. No significant difference in frequency of doxapram administration between groups was noted. Doxapram resulted in higher respiratory scores and significantly increased the ability to determine normal laryngeal function. Ketamine did not allow for a reduction in propofol dose and caused increased respiratory depression, making ketamine a poor addition to propofol for laryngeal function examination. Regardless of the protocol used, laryngeal function should be determined in conjunction with the respiratory phase and depth of respirations. Patients with either absent or shallow respirations should receive doxapram for accurate evaluation of laryngeal function.

Clinical Photograph: “A Third Arythenoid?”

A case of anatomical variation of the hyoid bone in a girl is presented. Over-extended bending of the elongated and curved right side of the hyoid bone, may project to the lumen of the supraglottic area as the patient presented. She had a foreign body sensation in her throat, and on fiber optic laryngeal examination, a bulge’s appearance as a “third arythenoid” was seen. We present the clinical finding and the picture of a “third arythenoid” with literature review.

Cepstral Characteristics of Voice before, during and after Menopause: A Cross-sectional Study

ABSTRACT Background Previous studies on effects of menopause on voice characteristics have not compared the voice characteristics before, during and after menopause. It is also possible that these voice changes cannot be captured by traditional acoustic measures such as frequency and amplitude perturbation measures. Hence a robust acoustic tool such as cepstrum was chosen to capture these vocal changes before, during and after menopause and hence the present study was attempted. Method The present study followed a cross-sectional study design. The participants consisted of 25 premenopausal women, 25 perimenopausal women and 25 postmenopausal women. Sustained production of/a/ and narration was recorded using Z tool and cepstral peak prominence (CPP) and smoothened cepstral peak prominence (CPPS) was analyzed. Results The results of one-way ANOVA revealed that there was a significant main effect of the group at p < 0.05 for all the cepstral measures targeted in the study. Post hoc analysis indicated that there was no significant difference between pre and perimenopausal women for all the cepstral measures at p < 0.05. However, there was a significant difference between pre and postmenopausal women and peri and postmenopausal women at p < 0.05. These results suggests that postmenopausal women had overall good voice quality than pre and perimenopausal women. Conclusion Results indicated that post menopausal women had increased cepstral measures when compared to pre and perimenopausal women. Further, studies are required to correlate laryngeal examination and hormonal levels with that of the voice changes before, during and after menopausal women. How to cite this article Balasubramanium RK, Bhat JS. Cepstral Characteristics of Voice before, during and after Menopause: A Cross-sectional Study. Int J Phonosurg Laryngol 2014;4(2):50-54.

Video-assisted unilateral cricoarytenoid laryngoplasty in 14 dogs with bilateral idiopathic laryngeal paralysis

Background: Unilateral cricoarytenoid laryngoplasty is commonly performed for treatment of idiopathic laryngeal paralysis in dogs. Determination of the appropriate tension applied to the suture can be difficult, particularly for the novice surgeon.Objective: To describe a technique for video-assisted unilateral cricoarytenoid laryngoplasty (VAUCAL) and to report short-term outcome in dogs undergoing VAUCAL.Animals and methods: Dogs (n = 14) with bilateral idiopathic laryngeal paralysis undergoing VAUCAL between August 2011 and May 2013 were evaluated. A cricoarytenoid suture was tensioned under video observation of the rima glottidis using a 5-mm rigid endoscope. Real-time visualization of arytenoid abduction during suture tensioning, and final arytenoid position were assessed. Requirement for additional intravenous anesthestic, intra- and post-operative complications and short-term outcomes were documented.Results: Adequate, real-time visualization of the larynx during tensioning of the cricoarytenoid suture was accomplished in 13/14 dogs. Additional intravenous anesthesia was required in 5/14 dogs to facilitate reintubation. Final arytenoid position was considered inadequate in two dogs on post-operative trans-oral laryngeal examination. Recurrence of clinical signs occurred in one dog three months following initial surgery. Owner outcome was deemed good (n = 8) or excellent (n = 6).Conclusions: VAUCAL is a feasible technique to permit direct real-time visualization of the larynx during tensioning of the cricoarytenoid suture, and enables assessment of final arytenoid position intra-operatively by the operating surgeon.Clinical importance: VAUCAL allows the operating surgeon to assess arytenoid abduction intra-operatively, at the time of knot placement. This technique may be particularly useful for the novice surgeon or surgeon in training.

Evaluating the Incidence, Clinical Significance and Predictors for Vocal Cord Palsy and Incidental Laryngopharyngeal Conditions before Elective Thyroidectomy: Is There a Case for Routine Laryngoscopic Examination?

Routine preoperative laryngeal examination remains controversial. We aimed to assess the utility of preoperative routine flexible laryngoscopy (FL) by looking at the incidence, clinical significance and predictors for preoperative vocal cord paresis (VCP) and incidental laryngopharyngeal conditions (LPC) in our consecutive cohort. A total of 302 patients underwent laryngeal examination by an independent otorhinolaryngologist and were specifically asked about voice/swallowing symptoms suggestive of VCP 1 day before surgery. As well as vocal cord (VC) mobility, the naso-pharynx and larynx were examined using FL. Any VCP and/or LPC was recorded. VCP was defined as reduced or absent movement in one or more VC. An LPC was considered clinically significant if the ensuing thyroidectomy was changed or deferred. Seven (2.3 %) patients had preoperative VCP, while an additional seven patients had an incidental LPC. Of the seven VCPs, five were caused by previous thyroidectomy, while two were caused by a benign goitre. The incidence of asymptomatic VCP in a previously non-operated cohort was 1/245 (0.41 %). Voice/swallowing symptoms (p = 0.033) and previous thyroidectomy (p < 0.001) were the two significant predictors for VCP. The seven incidental LPCs were vallecular cyst (n = 1), VC scar and polyp (n = 2), nasopharyngeal cyst and polyp (n = 3) and redundant arytenoid mucosa (n = 1); however, as they were benign, all seven patients proceeded to thyroidectomy as planned. Given the low incidence (0.41 %) of asymptomatic VCP in a previously non-operated cohort and that none of the seven LPCs were considered clinically significant, routine preoperative laryngoscopic examination should be reserved for those with previous thyroidectomy and/or voice/swallowing symptoms.

Effect of adenoid hypertrophy on the voice and laryngeal mucosa in children

IntroductionThe adenoids, or pharyngeal tonsils, are lymphatic tissue localized at the mucous layer of the roof and posterior wall of nasopharynx.Dysphonia defined as perceptual audible change of a patient's habitual voice as self judged or judged by his or her listeners.The diagnosis of dysphonia relies on clinical judgment based on phoniatric symptoms, auditory perceptual assessment of voice (APA) and full laryngeal examination. Patients and methodsOur study was conducted to evaluate the effect of adenoid hypertrophy on voice and laryngeal mucosa. The study sample composed of sixty children, forty of them had adenoid hypertrophy (patient's group) and twenty healthy children (control group). Patient's group composed of 17 boys (42.5%) and 23 girls (57.5%), while control group consists of 8 males (40%) and 12 females (60%). All patients and control group subjected to history taking, clinical examination, lateral soft tissue X-ray on the nasopharynx, APA based on the modified GRBAS scale and full laryngeal examination. The data are collected and analyzed statistically by using software SPSS. ResultsOur results showed that there is a significant association between adenoid hypertrophy and, degree of dysphonia, leaky voice, pitch of voice and laryngeal lesion.Adenoid hypertrophy did not associate with loudness of voice, as well as character (irregular, breathy and strained). Laryngeal lesions were detected in thirteen children from patient group (32.5%): nodules (n=6), thickening (n=5), congestion (n=2), while one child only out of 20 children of the control group had congestion (5.0%). ConclusionOur results showed the importance of the assessment of voice and laryngeal examination in patients with adenoid hypertrophy, also treating the minimal mucosal lesions that results from adenoid hypertrophy should be taken in consideration.

Factors confusing the diagnosis of laryngopharyngeal reflux: the role of allergic rhinitis and inter-rater variability of laryngeal findings

The objective of the study was to determine the inter-rater variability in assessment of laryngeal findings and whether diagnosing laryngopharyngeal reflux based on the laryngeal findings and history alone without considering allergic rhinitis leads to the overdiagnosis and overtreatment of laryngopharyngeal reflux. Patients with positive and negative skin prick tests were recruited from an allergy clinic in a tertiary teaching university hospital. All subjects completed the Reflux Symptom Index (RSI) and underwent laryngeal examinations by three physicians blinded to the skin prick test results and the Reflux Finding Score (RFS) was determined. RFS >7 or RSI >13 was considered reflux positive. Fleiss' kappa (κ) was used to measure inter-rater agreement. The inter-rater agreement was low for pseudosulcus vocalis (κ = 0.078), ventricular obliteration (κ = 0.206), diffuse laryngeal edema (κ = 0.204), and posterior laryngeal hypertrophy (κ = 0.27), intermediate for laryngeal erythema/hyperemia (κ = 0.42) and vocal fold edema (κ = 0.42), and high for thick endolaryngeal mucus (κ = 0.61). Although the frequency of allergy was high, there was no significant difference between allergy-positive and laryngopharyngeal reflux-positive patients. On logistic regression analysis, thick endolaryngeal mucus was a significant predictor of allergy (p = 0.012, odds ratio 0.264, 95 % confidence interval 0.093-0.74). The laryngeal examination for reflux is subject to marked inter-rater variability and allergic laryngitis was not misdiagnosed as laryngopharyngeal reflux. The presence of thick endolaryngeal mucus should alert physicians to the possibility of allergic rhinitis/laryngitis.