Preepiglottic Space Research Articles

Use of Point-of-care upper airway ultrasound during preanesthetic airway assessment to predict difficult intubation in adult patients with obesity

BackgroundUltrasound is a simple, noninvasive complementary tool for preoperative airway assessment. This study compared airway ultrasound and conventional airway assessments to predict difficult intubation. MethodsAirway assessment was performed in 99 patients scheduled for bariatric surgery using the following two parameters: El-Ganzouri score (EGS) and oblique transverse ultrasound view. The following measurements were gathered with ultrasound: pre-epiglottic space depth (pre-E), distance from the epiglottis to the mid-vocal cords (E-VC), mean distance between the skin and epiglottis (mDSE), distance between the skin and hyoid bone (DSHB), and tongue volume. After induction of anesthesia, direct laryngoscopy was performed and Cormack–Lehane (CL) classification was reported.CL grades 1 and 2 were classified as the easy laryngoscopy (EL) group, Grades 3 and 4 were classified as having a difficult laryngoscopy (DL). The crucial performance measure was the E-ability VC's to anticipate difficult intubation. Association between these factors and the CL categorization was a significant indication. ResultsIn 12.12 percent of cases, hard intubation was seen. The DL group had a lower E-VC than the EL group (0.9 ± 0.28 cm vs. 1.52 ± 0.3 cm; P -value less than0.001). The DL cutoff point was <1.22 cm, with 91.7% sensitivity and 83.9% specificity. The CL classification indicated a strongly positive association with the EGS and strongly negative association with the E-VC measurement (r = 0.700 and –0.828, consecutively; P-value less than 0.001), moderately positive correlation with mDSE and DSHB (r = 0.433 and 0.566, consecutively; P-value less than 0.001), and weakly positive correlation with pre-E and tongue volume (r = 0.331 and 0.344, respectively; P-value less than 0.001). ConclusionsUltrasound as a complementary measure to anticipate difficult intubation is beneficial with high sensitivity and low specificity in avoiding the hazards of unanticipated, difficult intraoperative laryngeal visualization.

Abstract No.: ABS2511: Ultrasound assessment of airway parameters and their clinical correlation to predict difficult airway and laryngoscopy.

Background&Aims:Increased tongue thickness, pre-epiglottic depth and anterior-neck soft tissue thickness are likely to be associated with difficultairways. This study was aimed to find out various ultrasound airway assessment measurements and their efficacy and correlation with difficult airway and laryngoscopy.Methods:A prospective hospital based observational study was conducted at KLEA’s Dr.Prabhakar Kore Hospital and MRC, KAHER, Belagavi, after attaining institutional ethical committee clearance, in 60 adult American Society of Anesthesiologists (ASA)I/II patients undergoing tracheal intubationunder general anaesthesia. Patients with head andneck or cervical spine pathology were excluded. Ultrasonographic assessmentof tongue thickness, ratio of Pre-E/E-VC and anterior neck soft tissue thickness at level of vocal cords weredone with patients in supine position, before induction of anaesthesia. These were compared with Cormack-Lehane grading assessed during laryngoscopy and intubation. These assessments were conducted to investigate the potential predictive value of their combination for difficult laryngoscopy.Results:Using Pearson’s correlation, tongue thickness was found to be highly significant in correlation with the Cormack-Lehanegrading along with ratio of Pre-E/E-VC thus to predict difficult laryngoscopy with a significant p value of <0.0001. Thesensitivity of Pre-E/E-VC ratio was found to be 91.67% with a diagnosing accuracy of around 82%. Conclusion:The ultrasound parameters have greater sensitivity and specificity than conventional airway tests. The maximum vertical tongue thickness and ratio of pre-epiglottic space to distance from epiglottis to midpoint-of-vocalcords have better prediction for difficult laryngoscopy.

Abstract No. : ABS1378: Correlation between upper airway ultrasound and Cormack- Lehane grading during laryngoscopy-A prospective study

Background & Aims:Difficult and failed tracheal intubation after direct laryngoscopy is a dreaded complication of general anaesthesia. Preoperative prediction of the Cormack-Lehane (CL) grade with ultrasonographic measurements of ANS-Hyoid, ANS-VC, PES&EVL can help in better airway management during general anaesthesia.Methods:We studied 100 patients undergoing elective surgery under general anaesthesia. Study was carried out in two phases. Firstly, during preanaesthetic checkup, Mallam pati grade (MPG), Sternomental distance (SMD), Thyromental distance (TMD) and ultrasound measurements of the anterior neck soft tissue thickness at the level of the hyoid (ANS-Hyoid), at the level of the vocal cords (ANS-VC) and ratio of the depth of the pre-epiglottic space (Pre-E) to the distance from the epiglottis to the mid-point between the vocal cords (E-VC) were obtained, CL grade was noted during laryngoscopy. Chi-square test wasapplied to predict any statistically correlation between measurement of ultrasonographic parameters and CL grade.Results:The incidence of difficult intubation was 15%. An ANS-VC>0.32 had sensitivity of 100% in predicting a CL grade of 3 and4, which was higher than ANS-hyoid, PES/EVL, MPG, SMD, TMD, while specificity and PPV were lower. Conclusion:Ultrasound is a useful test in airway assessment. ANS-VC>0.32 is a potential predictor of difficult intubation. ANS-hyoid, PES/EVL are not indicative of difficult intubation.

Airway Ultrasound as Predictor of Difficult Direct Laryngoscopy: A Systematic Review and Meta-analysis.

BACKGROUND:Despite several clinical index tests that are currently applied for airway assessment, unpredicted difficult laryngoscopy may still represent a serious problem in anesthesia practice. The aim of this systematic review and meta-analysis was to evaluate whether preoperative airway ultrasound can predict difficult direct laryngoscopy in adult patients undergoing elective surgery under general anesthesia.METHODS:We searched the Medline, Scopus, and Web of Science databases from their inception to December 2020. The population of interest included adults who required tracheal intubation for elective surgery under general anesthesia without clear anatomical abnormalities suggesting difficult laryngoscopy. A bivariate model has been used to assess the accuracy of each ultrasound index test to predict difficult direct laryngoscopy.RESULTS:Fifteen studies have been considered for quantitative analysis of summary receiver operating characteristic (SROC). The sensitivity for distance from skin to epiglottis (DSE), distance from skin to hyoid bone (DSHB), and distance from skin to vocal cords (DSVC) was 0.82 (0.74–0.87), 0.71 (0.58–0.82), and 0.75 (0.62–0.84), respectively. The specificity for DSE, DSHB, and DSVC was 0.79 (0.70–0.87), 0.71 (0.57–0.82), and 0.72 (0.45–0.89), respectively. The area under the curve (AUC) for DSE, DSHB, DSVC, and ratio between the depth of the pre-epiglottic space and the distance from the epiglottis to the vocal cords (Pre-E/E-VC) was 0.87 (0.84–0.90), 0.77 (0.73–0.81), 0.78 (0.74–0.81), and 0.71 (0.67–0.75), respectively. Patients with difficult direct laryngoscopy have higher DSE, DSVC, and DSHB values than patients with easy laryngoscopy, with a mean difference of 0.38 cm (95% confidence interval [CI], 0.17–0.58 cm; P = .0004), 0.18 cm (95% CI, 0.01–0.35 cm; P = .04), and 0.23 cm (95% CI, 0.08–0.39 cm; P = .004), respectively.CONCLUSIONS:Our study demonstrates that airway ultrasound index tests are significantly different between patients with easy versus difficult direct laryngoscopy, and the DSE is the most studied index test in literature to predict difficult direct laryngoscopy. However, it is not currently possible to reach a definitive conclusion. Further studies are needed with better standardization of ultrasound assessment to limit all possible sources of heterogeneity.

Laryngeal spaces in the newborn larynx

ObjectivesDistributions of laryngeal spaces are important in understanding their functional significance. However, laryngeal spaces in the newborn larynx are enigmatic. MethodsFive normal human newborn larynges were investigated using whole organ serial section technique. ResultsThe chief newborn laryngeal spaces were the preepiglottic space, the paraglottic space and the cricoid area. They consisted of an areolar tissue area composed of brown adipose tissue (immature adipose tissue) and loose elastic and collagen fibers. The newborn preepiglottic space was immature and occupied a small area anterior to the epiglottis. The epiglottis lied on a somewhat horizontal axis and was partially obscured behind the hyoid bone. The hyoid bone overlapped the thyroid cartilage, partially obscuring the superior thyroid notch. The thyroid cartilage was present close to the hyoid bone and the thyrohyoid membrane ran between the superior surface of the thyroid lamina, and not the anteroinferior, but the posteroinferior surface of the hyoid bone. The preepiglottic space was located anterior, lateral and posterolateral to the thyroepiglottic ligament. However, the preepiglottic space was located anterior to the epiglottic cartilage. As seen in adults, the paraglottic space existed medial to the lamina of each bilateral thyroid cartilage. Each bilateral cricoid area was located along not only the superomedial but also the medial portion of the cricoid arch on both sides. ConclusionsAs the child grows, the preepiglottic space, occupying a small area anterior to the epiglottis, likely grows as the larynx descends and acquires the human adult vocal tract. From the functional histoanatomical point of view, the newborn laryngeal spaces appear to be favored for respiration and maintenance of a protective sphincter for the lower airway over phonation.

Comparative Study between two Ultrasound Aided Methods in PreoperativeAssessment of Difficult Airway in Obese Patients

Abstract Background Unpredictable difficult laryngoscopy remains a challenge for anaesthesiologists, especially if difficult ventilation occurs. So, accurate airway assessment should always be performed so as to provide appropriate planning and management of expected difficult intubation and to limit any unexpected difficulties. Airway assessment using ultrasound has been proposed recently as a useful, simple and non-invasive bed side tool as an adjunct to clinical methods. Objective To establish whether correlations existed between two ultrasound measurements and the Cormack–Lehane grade during direct laryngoscopy, and whether these measurements are useful in predicting are stricted or difficult view especially in morbid obese individuals. The first is the measurement of the hyomental distance of the patient in neutral position of the neck and in fully extended neck calculating the ratio between both of them. While the second is the measurement of anterior cervical soft tissue thickness at three anatomical levels (hyoid bone, thyrohyoid membrane or ‘pre epiglottic space’ and anterior commissure). We chose these two new measurements from among the various ultrasound assessments made in previous studies because of their simplicity of execution in normal clinical and in emergency settings. Patients and Methods The current study is a prospective comparative clinical trial of assessment of difficult air way using two different ultrasound aided techniques in comparison to Cormack and lehane scoring system. Those patients were chosen upon some inclusion and exclusion criteria; inclusion criteria were (Age of the patient (25-60y), ASA I-II patients, Obese patients with body mass index &amp;gt; 30 kg /m2 and Pts undergoing bariatric surgery) and exclusion criteria were (Pathology of the airway (tumors), Deformity of the airway anatomy (burns, scars), History of facial, cervical, pharyngeal and epiglottis surgery or trauma, Patients with most teeth lost and Patient refusal). Results Regarding U/S measurements in method A patients; the average HMD-neutral of A patients was (53.58±5.33) mm, the average HMD-extension was (58±7.82) mm, and the average HMDR was (1.07±0.06). It showed highly significant decrease in HMD extension and HMDR in difficult group, compared to easy group, in A group of patients (p &amp;lt; 0.01respectively). Non-significant difference as regards HMD-neutral U/S measurements in method A (p &amp;gt; 0.05). Conclusion Ultrasonography can be a valuable adjunct in this aspect of airway assessment. Ultrasound assessment of pre-epiglottic tissue thickness at the level of the thyrohyoid membrane may be useful to predict restricted/difficult direct laryngoscopy and difficult intubation. The ratio of hyomental distance between neutral and extended positions may also be a good predictor of difficult direct laryngoscopy.

Transoral laser microsurgery in locally advanced laryngeal cancer: Prognostic impact of anterior versus posterior compartments.

To evaluate the importance of larynx compartments in the prognosis of T3-T4a laryngeal cancer treated with transoral laser microsurgery. Two hundred and two consecutive pT3-T4a larynx carcinomas. Pre-epiglottic space involvement, anterior and posterior paraglottic space (PGS) involvement, vocal cord, and arytenoid mobility were determined. Local control with laser (LC), overall survival (OS), disease-specific survival (DSS), and laryngectomy-free survival (LFS) were evaluated. The lowest LC was found in tumors with fixed arytenoid. In the multivariate analysis, positive margins (hazard ratio [HR]=0.289 [0.085-0.979]) and anterior (HR=0.278 [0.128-0.605]) and posterior (HR=0.269 [0.115-0.630]) PGS invasion were independent factors of a reduced LC. Anterior (HR=3.613 [1.537-8.495]) and posterior (HR=5.195 [2.167-12.455]) PGS involvement were independent factors of total laryngectomy. Five-year OS, DSS, and LFS rates were 63.9%, 77.5%, and 77.5%, respectively. Patients with posterior PGS presented a reduced 5-year LFS. Tumor classification according to laryngeal compartmentalization depicts strong correlation with LC and LFS.

Occult lymph node metastasis in patients with laryngeal cancer and relevant predicting factors: a single-center experience.

To reveal the incidence and predictive parameters of occult cervical lymph node metastasis (LNM) in patients with cN0 laryngeal squamous cell cancer (LSCC) who underwent surgery as definitive treatment. Patients with cN0 laryngeal cancer who had undergone elective neck dissection together with partial or total laryngectomy between January 2006 and November 2020 were retrospectively analyzed. Clinical and histopathologic predictors of occult metastasis were also analyzed. Follow-up data were used to obtain recurrence and survival analysis. A total of 86 patients with a mean age of 62.5 years were included in the study. Occult LNM was detected in 15 (17.4%) patients. Tumor grade, pT stage, thyroid cartilage invasion, and extralaryngeal extension were found to predict occult neck metastasis in univariate analysis. The mean follow-up time was 60.7 months and in the survival/recurrence analysis, pT stage, tumor location, tumor grade, presence of occult metastasis, pre-epiglottic space involvement. and extralaryngeal extension were found to predict poorer outcome. Overall occult LNM is low (17.4%) in N0 laryngeal cancer, but the presence of LNM is a poor prognostic factor. Correct determination of the neck status and proper treatment is crucial. The incidence of LNM is very low in T1-T2 stages and well-differentiated tumors. The "wait and see" strategy may be applied in T1-T2 cases as well as selected T3 cases with well-differentiated tumors.

Association of tumor volume and outcomes in T3 larynx cancer with organ preservation approach.

e18044 Background: Organ preservation approaches to treatment of locally advanced larynx cancers are widely used and consist of radiotherapy (RT) with or without concurrent systemic therapy (CRT). Analyses of the National Cancer Database point to decreasing survival as CRT became widely adopted in place of total laryngectomy (TL). Tumor volume in T3 laryngeal tumors has been postulated as one variable to explain this finding, with higher volume associated with lower local control based on small sample size studies largely in pre-intensity modulated radiotherapy (IMRT) era, and low volume T3 tumors being associated with improved local control with CRT. We sought to validate these findings in a contemporary cohort of T3 larynx patients treated with IMRT. Methods: This was a national, multicentre retrospective cohort study of patients diagnosed with American Joint Committee on Cancer (AJCC) T3 N0-3 M0 glottic and supraglottic cancers who underwent curative intent IMRT with or without systemic treatment from 2002-2018. Tumor volumes were calculated using a validated standardized approach by a Neuroradiologist. Primary predictor was tumor volume, primary outcome was local control (LC), and secondary outcomes included overall survival (OS), as well as late grade 3+ toxicities. Kaplan Meier estimates and log-rank tests were used for survival analyses, with Cox proportional hazards used for univariable analyses. Results: 246 patients met inclusion criteria, 147 glottic and 99 supraglottic cancers. At baseline, glottic patients were more likely to be male (p &lt; 0.01), have a fixed vocal cord (p &lt; 0.01), not have pre-epiglottic space invasion ( &lt; 0.01), be cN0 (p &lt; 0.01), and have lower grade tumors (p &lt; 0.01). Mean tumor volumes for glottic and supraglottic tumors were 5.0 (4.2-5.8) cc and 13.0 (10.3–15.6) cc respectively. Univariable analysis showed systemic therapy was associated with improved local failure (HR 0.49, 95%CI 0.24 – 0.99, p = 0.05). Within the glottic cohort, tumor volume was not associated with local failure (HR 1.09, 95%CI 0.71 – 1.67, p = 0.38), however having a local failure event was associated with increased feeding tube dependence (HR 2.52, 95%CI 1.05 – 6.02, p = 0.04). Median local failure free survival in the overall cohort was 28.5 months, with median OS 23.2 months. There was a trend towards improved local control in the supraglottic cohort compared to glottic patients (log-rank p = 0.08), but the supraglottic cohort had significantly worse overall survival (log-rank p = 0.02). Conclusions: In this retrospective cohort study, there were baseline and outcome differences between patients with T3 glottic and supraglottic larynx cancer, with worse overall survival in supraglottic patients. Tumor volume was not associated with local control in the glottic cohort. These findings are pending further validation in a larger cohort and will be analyzed separately for supraglottic tumors.

Prognostic Features in Intermediate-Size Supraglottic Tumors Treated With Open Supraglottic Laryngectomy.

We investigated growth patterns and pathological features in intermediate-size laryngeal carcinoma amenable to supraglottic laryngectomy. Retrospective cohort study. We reviewed patients who underwent an open partial horizontal laryngectomy (OPHL) type I. We analyzed pathological data, tumor sizes, overall survival, disease-specific survival, local control, and laryngeal preservation. Results were stratified between three groups: group I comprised patients with endolaryngeal carcinoma, group II comprised patients with anterior epilaryngeal carcinoma who underwent an OPHL type I + base of tongue (BOT), group III comprised patients with lateral epilaryngeal carcinoma who underwent an OPHL type I + pyriform sinus (PIR). Sixty-eight patients were analyzed. The 5-year rates of overall survival, disease-specific survival, local control, and laryngeal preservation were 68.4%, 83.7%, 91.6%, and 98.3%, respectively. The tumor sizes at pathological examination were similar between the three groups (mean 27 mm, P = .80) and were associated with pathological features, notably pre-epiglottic space (PES) invasion (24.9 mm vs. 32.2 mm, P = .01), occult invaded lymph nodes (22.6 mm vs. 29.9 mm, P = .03), and trends for margins status (26.5 mm vs. 29.3 mm, P = .45). The risks of PES invasion, occult lymph nodes, and positive margins, respectively, predominated in group I (41.7%), group II (56.3%), and group III (23.3%). In intermediate-size tumors amenable to supraglottic laryngectomy, pathological features are associated with tumor size according to group stratification based on tumor location. 4 Laryngoscope, 131:E1980-E1986, 2021.

CHARACTERISTICS AND SPREAD PATTERN OF LARYNGEAL CARCINOMA : A TERTIARY CARE STUDY

INTRODUCTION Laryngeal cancer is the eighteenth most common cancer in the UK. It has strong socioeconomic association, wide geographical variations. This study is highly relevant in India where factors like poor socio-economic conditions, oral consumption of tobacco in its various forms, alcohol, smoking habits in form of beedi and cigarette, lack of awareness about cancer, negligence towards the symptom of voice change and primary treatment from quacks , are highly prevalent. MATERIALS AND METHODOLOGY This prospective cohort study was carried out at Tertiary care Hospital over a period of 1 year 4 months( April 2018 to July 2019). Patients attending at our OPD with symptoms of horseness, dysphagia, stridor and other symptoms of Laryngeal Carcinoma were subjected to detailed clinical examination including FOL to confirm the presence of any growth. All patients with growth or vocal cord irregularity or any suspicious lesions underwent biopsy. Socio-demographic, risk factors , characteristics of primary tumor- endoscopic, radiological and histopathological and spread pattern and node status analysed. RESULTS Major bulk of patients belonged to 55-74 years (combined). The mean age of diagnosis is 66.06 years.Males were affected more than females (7.57:1).Majority of patients were farmers (57%) and majority 45(75%) belonged to rural areas. Most patients belonged to low socioeconomic class 30 (50%).Smoke tobacco and smoke tobacco plus alcohol were the major risk factors for laryngeal carcinoma.Majority of patients presented with dysphagia (75%), followed by foreign body sensation (72%), hoarseness (67%), Neck swelling (50%). Cartilage invasion was present among 25% of cases , Both pre-epiglottic and paraglottic space involvement was around 18% and exolaryngeal spread present in 8% of cases.Among them 100% cases delayed symptom recognition was present. 50% cases was attributed due to socio-demographic pattern, 33% due to pshycosocial and behavioural (anxiety) and 13% due to delay in practitioner referral.Among Proliferative and Ulceroproliferative N+ is more than N0.Both moderately differentiated and poorly differentiated had more percentage of N+.In Supraglottic tumor Pre-epiglottic space, Paraglottic Space and cartilage invasion was present in equal proportions. In glottic tumor cartilage invasion and exolaryngeal spread was more common. CONCLUSION Supraglottic tumor being common have tendency for lymphatic spread. It mainly presents with dysphagia and hoarseness later. Majority of patients were diagnosed in stage III and stage IV. This is not desirable and causes for delayed diagnosis must be addressed publicly. Early stage tumor have excellent prognosis with advent of radiotherapy and surgical morbidities can be avoided. The HPE reveals high grade of differentiation is associated with low node status. CT features serve as an excellent tool in identifying spread and node involvement and also management protocol.

Durable complete regression of laryngeal cancer with pre-epiglottic space invasion after radiochemotherapy and the incidental use of ACE-inhibitor: case report

Durable complete regression of laryngeal cancer with pre-epiglottic space invasion after radiochemotherapy and the incidental use of ACE-inhibitor: case report

Measurement of subglottic diameter and distance to pre-epiglottic space among Chinese adults.

Proper endotracheal tube (ETT) size selection and identification of potentially difficult airways are important to reduce laryngeal injury during intubation. However, controversies exist concerning transverse subglottic diameter-the narrowest part of the airway-and the distance to pre-epiglottic space. Because few studies have reported the distance from skin to the midpoint of the epiglottis (DSE) among normal individuals, whether the DSE varies between individuals and by ethnicity remains uncertain. The present study aims to investigate the sonographic subglottic diameter and DSE among healthy Chinese adults. Healthy volunteers were recruited at National Taiwan University Hospital between October and November 2019. Exclusion criteria included pre-existing airway or respiratory diseases, neck tumors, and a history of neck operation. Age, sex, height, weight, body mass index (BMI), sonographic DSE, and transverse subglottic diameter were recorded. A total of 124 participants were enrolled. The average age was 32.5 ± 10.4 years and 63 participants (51%) were males. The subglottic diameter was positively associated with sex (males, 14.40 mm; females, 11.10 mm, p < 0.001) and BMI (underweight, 12.13 mm; normal weight, 12.47 mm; overweight, 13.80 mm; obese, 13.67 mm, p = 0.007). Moreover, the DSE was shorter in males (male, 16.18 mm; females, 14.54 mm, p < 0.001) and participants with increased BMI (underweight, 13.70 mm; normal weight, 15.06 mm; overweight, 16.58 mm; obese, 18.18 mm, p < 0.001). As compared with other ethnicity, a smaller size of subglottic diameter and a shorter DSE were noted among Chinese participants, and we suggest that a relatively smaller size of endotracheal tube selection should be considered in tracheal intubations.

Unanswered Questions on the Optimal Extent of Tongue Cancer Resections.

Owing to the site- and stage-dependent molecular changes beyond the excised surgical margins of mucosal head and neck squamous cell cancers [HNSCC], an absolute cutoff for safe margins is difficult to define. Entrapment of the primary tumor in a specified compartment by a barrier clearance concept can circumvent this to a considerable extent, but it is not possible in all sites. A case of recurrent squamous cell cancer (SCC) of the tongue which had undergone wide excision of the lesion twice and later required a total laryngectomy because of crossover of the recurrent disease to the preepiglottic space and thereby to the glottis-supraglottic region is presented as an example to illustrate this predicament.

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.

Imaging checklist for preoperative evaluation of laryngeal tumors to be treated by transoral microsurgery: guidelines from the European Laryngological Society.

The modern availability in daily practice of different DICOM viewers allows physicians to routinely evaluate computed tomography (CT) and magnetic resonance (MR) scans of patients in the pre-, intra-, and postoperative settings. Their systematic use, together with a close surgeon-radiologist cooperation, may greatly improve outcomes of patients to be treated by transoral microsurgery for laryngeal cancer. We herein propose guidelines for systematic evaluation of CT/MR images taken from patients affected by supraglottic and glottic cancer to be treated by transoral microsurgery. A methodical, step-by-step approach focused on laryngeal anatomy, systematically looking at each true and false vocal folds, anterior commissure, laryngeal ventricle, subglottic area, epiglottis, thyroid, cricoid, and arytenoid cartilages, posterior commissure, crico-arytenoid unit, paraglottic and pre-epiglottic spaces, and possible extra-laryngeal extension is proposed. This checklist may be useful before imaging performance (to focus on specific issues to be detailed by the radiologist), as well before and during surgery for the specific evaluation of details to be cleared during transoral microsurgery. Detailed preoperative evaluation of supraglottic and glottic anatomy is essential prior to any transoral approach for neoplastic disease. The proposed imaging checklist described herein represents a step-by-step guide to surgeons performing this kind of interventions and an aid in achieving a meticulous approach from a surgical perspective.

An observational study to evaluate the role of ultrasound in the prediction of difficult laryngoscopy

Background: Difficult laryngoscopy (DL) is challenging when difficult ventilation occurs during standard laryngoscopy. For airway assessment, the common clinical airway predictors have low sensitivity (Sn) and specificity (Sp) with a limited predictive value. Ultrasound can be a useful tool for predicting such difficulties. We aimed to evaluate the usefulness of several sonographic airway parameters in predicting DL in adults. Patients and Methods: This prospective observational study included 120 patients who underwent elective surgery requiring general anesthesia with direct laryngoscopy (Macintosh blade) and endotracheal intubation. Ultrasonography (USG) assessment included preepiglottic space (PES), hyomental distance (HMD), distance from skin to the hyoid bone-skin (DSHB), and distance from skin-to-epiglottis midway between the hyoid bone and thyroid cartilage distance from skin to epiglottis midway (DSEM). Demographic variables and Cormack-Lehane (CL) grading for laryngoscopy (CL grade 1, 2-easy; 3, 4-difficult). Receiver operating characteristic (ROC) analysis was done, and area under the curve (AUC) was calculated to determine the best predictor of DL. Results: DL was present in 22.50% of patients. Compared to those with easy laryngoscopy, patients with DL had lesser HMD (4.55 vs. 4.96, P = 0.002), and comparable DSHB, DSEM, and PES. Among the various US parameters for predicting DL, we found the highest Sn of DSHB (74.07%); highest Sp of HMD (86.02%); highest positive predictive value of HMD (50%); and highest negative predictive value of HMD (85.1%). ROC curve analysis showed HMD to be the best predictor for DL with the highest AUC of 0.684. Conclusion: DL is common, present in 22.5% patients. US is a novel modality for predicting the DL, especially HMD, which showed the highest AUC among DSHB, DSEM, and PES.

Ultrasonography versus conventional methods (Mallampati score and thyromental distance) for prediction of difficult airway in adult patients

ABSTRACT Background The poor reliability of traditional screening tools to identify a potentially difficult airway makes the difficult laryngoscopy and tracheal intubation rate remains at 1.5–13%.The hypothesis is that fat pads affect the view during direct laryngoscopy so the increasing thickness of pretracheal soft tissue or pre-epiglottic space could be strong predictors of difficult laryngoscopy as the mobility of the pharyngeal structures is impaired. Upon that, we aimed to evaluate ultrasound-measured distance from skin to epiglottis for prediction of difficult laryngoscopy in Egyptian population. Methods This was a prospective single blind randomized clinical study conducted on 80 patients requiring general anesthesia.Preoperatively, airway evaluation was performed using three parameters including Mallampati score, thyromental distance and ultrasound-measured distance from skin to epiglottis at the level of thyrohyoid membrane. The primary outcome was to correlate ultrasound measured distance from skin to epiglottis with difficult laryngoscopy in Egyptian population using Cormack – Lehane grading. Results Difficult laryngoscopy group displayed greater thickness of the ultrasound measured distance from the skin to epiglottis(2 ± 0.3 cm versus 1.7 ± 0.3 cm; p = 0.002). The cut-off point for difficult laryngoscopy was >1.85 cm with sensitivity of 80%, specificity of 70.8% and area under the receiver operating characteristic curve was 0.759. Mallampati score and thyromental distance had poor area under the curve = (0.651, 0.670 respectively). Conclusion Our study revealed good correlation between ultrasonograohic measurement of the skin to epiglottis distance and Cormack-Lehane grade in Egyptian population, therefore it might be considered as a predictor of difficult laryngoscopy. Clinical trial number NCT03799055.

Comparative Study of Preoperative Airway Assessment by Conventional Clinical Predictors and Ultrasound-Assisted Predictors.

Aims:The aim of this study is to evaluate the effectiveness of airway sonographic parameters as the predictors of difficult laryngoscopy and to evaluate the validity of combined sonographic and clinical tests.Materials and Methods:This prospective and observational study analyzed a sample of 200 patients who were categorized as having easy (Grades 1 and 2) or difficult (Grades 3 and 4) laryngoscopy based on the laryngoscopic criteria of Cormack-Lahane (CL). Sonographic parameters, including the anterior neck soft-tissue thickness at the level of vocal cord (ANS-VC), ANS tissue thickness at the level of hyoid, and ratio of depth of pre-epiglottic space to distance from epiglottis to midpoint of the distance between vocal cords and clinical parameters, including modified Mallampati class, thyromental distance, and hyomental distance ratio (HMDR), were analyzed. Univariate and multivariate regression analysis was used for the statistical analysis.Results:Twenty patients (10%) were categorized as having difficult laryngoscopy. Statistically significant differences between patients with difficult and easy laryngoscopy were noted for 5 of 6 parameters. The diagnostic validity profiles showed variable sensitivity (26.5%–87.5%) and good specificity (58.9%–94.2%) and negative predictive value (88.8%–97.03%). ANS-VC has the highest sensitivity (87.50%) and area under curve value (0.887), whereas HMDR showed highest specificity (94.2%) and highest accuracy (89.60%) which means it has low false-positive prediction rate. The combination of tests improved the diagnostic validity profile (highest area under the curve, 0.897).Conclusion:Sonographic predictors can help in identifying difficult laryngoscopy. Combined clinical and ultrasonographic parameters showed better validity profiles in comparison to the individual tests.

The Evaluation of Upper Airway: Point of Care Ultrasound vs. Conventional Tests

Objective: The ultrasound-guided interventions have gained widespread popularity in several aspects of anesthesia practice. In this study, we aimed to compare the preoperative evaluation tests and sonographic measurements of the upper airway for the prediction of a potentially difficult airway.&#x0D; Material and Methods: In this prospective observational study, we enrolled 136 adult patients undergoing elective surgery under general anesthesia. The Modified Mallampati classification, thyromental distance, sternomental distance, and Cormack-Lehane scores were recorded. Sonographic measurements included pre-epiglottic space (PES), the distance between the midpoints of vocal cords and epiglottis (EVC). The ratio was interpreted. Main outcome is to determine the sensitivity and specificity of the upper airway ultrasound for the prediction of a potentially difficult airway.&#x0D; Results: There was no statistically significant relationship between body mass index value and thyromental distance, Thyromental/Sternomental Ratio and PES/EVC ratio, Cormack-Lehane, Mallampati classification and thyromental/sternomental distance ratio (p&gt;0.05). The sonographic measurements of airway have no significance to predict the difficult intubation and the comparison between PES, EVC and the PES/EVC ratio and assessment tests (Cormack-Lehane, Mallampati classification, thyromental and sternomental distances) was insignificant. The sternomental distance measurement was predictive for the difficult airway only in patients having body mass index more than 31.6 kg m-2.&#x0D; Conclusion: Ultrasound is a useful tool for identifying the upper airway prior to anesthesia but the validity for the prediction of difficult airway is not clear. By increasing the clinical experiences and further investigations, a greater insight into its use will be gained.