Supraglottic Obstruction Research Articles

Supraglottoplasty as treatment of exercise induced laryngeal obstruction (EILO).

Breathing difficulties during exertion may be caused by exercise-induced laryngeal obstruction (EILO). The diagnosis depends on visualization of the larynx during exercise, i.e. by continuous laryngoscopic exercise (CLE) test. In case of severe supraglottic collapse and pronounced symptoms during strenuous exertion, surgical treatment (supraglottoplasty) has been suggested. The aims of this study were to evaluate outcome and patient satisfaction after supraglottoplasty for EILO and to compare our results with previously reported data. During the period December 2010 to October 2013, 17 patients diagnosed with moderate to severe supraglottic EILO were treated by supraglottoplasty with microlaryngoscopic laser technique at our institutions. The severity of patients symptoms (VAS score) and CLE scores was evaluated pre- and postoperatively. We found a decrease in patients symptoms from median 80 points VAS score preoperatively to 20 points postoperatively (p < 0.001) and a decrease in CLE sum score from median 4.0 points to 2.5 points (p < 0.05). Several previous studies have recommended surgery for selected patients with supraglottic involvement, but these have mainly been based on case reports or on very few patients. This study is the second larger-scale study that documents the positive effect of supraglottoplasty as treatment of EILO in terms of reduced respiratory symptoms and decreased laryngeal obstruction assessed by post-operative CLE test. We suggest that surgery is a well-tolerated and effective treatment option for selected EILO patients with moderate to severe supraglottic obstruction during exercise and a high level of physical activity.

Surgical treatment is effective in severe cases of exercise-induced laryngeal obstruction: A follow-up study

Conclusions: Surgery is an effective treatment in severe cases of supraglottic exercise-induced laryngeal obstruction (E-ILO). Conservatively treated subjects and subjects tested negative for E-ILO, who still experience breathing problems 1–3 years after diagnosis, tend to adjust their physical activity to a greater extent than surgically treated subjects. Objective: To investigate how symptoms and level of physical activity change over time in patients with E-ILO who have undergone surgery, patients with E-ILO treated conservatively and patients who tested negative for laryngeal obstruction at continuous laryngoscopy exercise-test (CLE-test). Methods: Patients referred for exercise-induced breathing difficulties answered questionnaires at diagnostic CLE-test and at follow-up. Questions regarded exercise-induced breathing problems, current physical activity level, and medical history of asthma and perennial allergy. Results: Out of 84 invited subjects, 59 (70%) answered both questionnaires. Surgically treated subjects had less breathing problems at follow-up compared with conservatively treated subjects and subjects who tested negative (p < 0.001). None of the surgically treated subjects were less physically active or had changed sport due to exercise-induced dyspnoea, whereas 41.7% of the conservatively treated subjects had made such adjustments (p < 0.001).

Beyond the fire: smoke inhalational injury as a respiratory concern

In fire events, smoke inhalation is the leading cause of death in survivors of the primary fire mortality. Direct upper airway thermal injury is only one of the contributing mechanisms. Others may be related to the nature of the combusted (or incomplete combusted) materials in the scene; eg.; aldehydes, sulphur oxides and nitrogen as a cotton combustion products, while burning polyvinylchloride (PVC's) releases carbon monoxide (CO) and hydrochloric acid, among more than 75 potentially toxic compounds including cyanide. Hot carbonated gaseous materials and soot may lead to supraglottic, glottic, or infraglottic airway obstruction however; significant hypoxemia is not the typical sign in acute cases without aspiration or parenchymal lung injuries. Injury may not manifest until after 48 hours.

연성 후두개를 가진 수면 무호흡 환자에서 부분후두개절제술 시행 1예

Floppy epiglottis (FE) which is a kind of laryngomalacia is a rare disease in adult. FE can cause upper airway obstruction, sleep apnea disorder that should be differential diagnosis from asthma attack or paradoxical vocal cord movement. The patients can be observed the prolapsed epiglottis and supraglottic airway obstruction on laryngoscope during inspiration. A recent study has demonstrated that continuous positive airway pressure (CPAP) of the initial treatment aggravated airway obstruction in patients with FE. The other study has demonstrated that partial epiglottectomy is effective in the treatment FE. We present one case of floppy epiglottis with partial epiglottectomy. (J Clinical Otolaryngol 2014;25:215-218)

Supraglottic Obstruction in an Adult with Inspiratory Arytenoid Cartilage Prolapse

Laryngomalacia (LM) has become the default diagnostic term for any patient who might struggle with stridor and dyspnea secondary to floppy, insufficient, hypotonic, or passively collapsing supraglottal tissue characteristics. Despite the increasing incidence of this diagnosis, the etiology, work-up, and pathophysiology of LM remain poorly understood and controversial to date. Objectives: The purpose of this paper is to illustrate the history, unique physical examination findings, and multivaried and creative treatments rendered to an adult patient of ours who struggled with profound signs and symptoms of Type 1 LM. Methods: This is a case study of idiopathic aerodynamic supraglottic collapse that occurred in an otherwise healthy individual who had no prior history of connective tissue disorder, neurodegenerative disorder, or trauma. The patient’s history, examination, treatment, and review of the literature are discussed. Results: Laryngoscopy is the definitive test to evaluate supraglottic airway collapse. Supraglottoplasty is a safe and effective treatment for adult LM. Conclusions: The diagnosis of adult aerodynamic supraglottic collapse is an important entity to consider in patients presenting with dyspnea, stridor, or other breathing complaints. This case description illustrates the importance of laryngoscopy when evaluating patients with such signs and symptoms.

Eucapnic voluntary hyperventilation in diagnosing exercise-induced laryngeal obstructions

Exercise-induced laryngeal obstructions (EILOs) cause exercise-related respiratory symptoms (ERRS) and are important differential diagnoses to exercise-induced asthma. The diagnostic method for EILOs includes provocation to induce the obstruction followed by a verification of the obstruction and the degree thereof. The objective of the present study was to examine if a eucapnic voluntary hyperventilation (EVH) test could induce laryngeal obstructions laryngoscopically identical in subtypes and development as seen during an exercise test. EVH and exercise testing with continuous laryngoscopy were performed during a screening of two national athletic teams (n = 67). The laryngoscopic recordings were examined for usability, abnormalities and maximal supraglottic and glottic obstruction using two currently available methods (Eilomea and CLE-score). The participants were asked questions on ERRS, and whether the symptoms experienced during each provocation matched those experienced during regular training. A total of 39 completed both tests. There were no significant differences in subtypes and development thereof, the experience of symptoms, and specificity and sensitivity between the methods. Significantly more recordings obtained during the exercise test were usable for evaluation primarily due to resilient mucus on the tip of the fiber-laryngoscope in the EVH test. Only recordings of six athletes from both provocation methods were usable for evaluation using the Eilomea method (high-quality demand). Amongst these, a linear correlation was found for the glottic obstruction. EVH tests can induce EILOs. However, the present test protocol needs adjustments to secure better visualisation of the larynx during provocation.

Pathophysiology and diagnostic approach to laryngomalacia in infants

Laryngomalacia is defined as collapse of supraglottic structures during inspiration. It is the most common laryngeal disease of infancy. Laryngomalacia presents in the form of stridor, a high-pitched, musical, vibrating, multiphase inspiratory noise appearing within the first 10 days of life. Signs of severity are present in 10% of cases: poor weight gain (probably the most contributive element), dyspnoea with permanent and severe intercostal or xyphoid retraction, episodes of respiratory distress, obstructive sleep apnoea, and/or episodes of suffocation while feeding or feeding difficulties. The diagnosis is based on systematic office flexible laryngoscopy to confirm laryngomalacia and exclude other causes of supraglottic obstruction. Rigid endoscopy under general anaesthesia is only performed in the following cases: absence of laryngomalacia on flexible laryngoscopy, presence of laryngomalacia with signs of severity, search for any associated lesions prior to surgery, discrepancy between the severity of symptoms and the appearance on flexible laryngoscopy, and/or atypical symptoms (mostly aspirations). The work-up must be adapted to each child; however, guidelines recommend objective respiratory investigations in infants presenting signs of severity.

Perioperative Complications in Children With Apert Syndrome

Summary Objectives: To perform a retrospective, anesthesia case note review in children with Apert Syndrome. Aim: To identify perioperative complications in this group of patients. Background: Apert syndrome is a rare autosomal dominant disorder characterized by craniosynostosis, craniofacial anomalies, and severe symmetrical syndactyly (cutaneous and bony fusion) of the hands and feet. Children with this syndrome require general anesthetics for a number of different operations and procedures. Our institution has records of 71 children with Apert syndrome. Analysis of their general anesthetic records was undertaken, and the incidence of perioperative complications was investigated. Methods: A retrospective case note review was performed on 61 children with Apert syndrome over a 14-year period. There were a total of 509 general anesthetics administered to these children during this period of time. Results: There were a total of 31 perioperative respiratory complications occurring in 21 patients (6.1% of the total cases). Twenty-three of these complications were supraglottic airway obstruction (4.5% of total cases). Conclusions: We found there to be a low incidence of major perioperative major complications in this group of patients. Nevertheless, a significant proportion of these children have obstructive sleep apnoea and may develop supraglottic airway obstruction on induction and emergence from anesthesia due to the associated mid-face anatomical abnormalities.

Vallecular cyst in an infant: does your specimen show D2-40 immunoreactivity?

Vallecular cysts are infrequent causes of supraglottic obstruction causing stridor and swallowing difficulty in infants. When detected early in life, the management consists of marsupialization or resection. Supraglottic lymphangiomas of the tongue base and vallecula present with similar symptoms and time of presentation. Endoscopic visualization is traditionally considered to be sufficient in identifying and differentiating these. When a vallecular cyst is visually diagnosed by the surgeon during endoscopy, surgical treatment is provided at the same time. Obtaining a specimen is rarely considered for histopathologic diagnostic verification. However, the natural presentation of a cystic lymphangioma may be indistinguishable from a solitary vallecular cyst by endoscopy alone. This case presentation argues in favor of histopathologic diagnosis in vallecular cysts because the 2 may represent a continuum of disease. A vallecular mass with a single large mucus-filled cyst and adjoining edematous soft tissue extension into the tongue base and piriform sinus diagnosed as lymphangioma through D2-40 immunoreactivity is presented.

Management of a patient with tracheomalacia and supraglottic obstruction after thyroid surgery

We describe an unusual combination of dynamic supraglottic, glottic, subglottic, and intrathoracic airway obstructions following a total thyroidectomy. These problems were anticipated, documented videographically, and managed preemptively. Following a total thyroidectomy, we replaced the endotracheal tube with a laryngeal mask airway, namely, the LMA-Classic™, in a patient with symptomatic tracheal compression and probable obstructive sleep apnea. Spontaneous ventilation was observed bronchoscopically through the LMA-Classic. Supraglottic swelling, extraglottic collapse on inspiration, and intrathoracic collapse on expiration were documented prior to recovery. These observations were of sufficient concern to warrant reinsertion of the endotracheal tube and subsequent tracheal extubation over a tube exchanger. Thereafter, we provided face-mask continuous positive airway pressure using a Boussignac mask with an endotracheal ventilation catheter in situ. Acute airway collapse following thyroid surgery is a rare and potentially serious complication. Diagnosis by conventional methods may be insensitive. Difficulties may not be apparent until the patient becomes distressed after tracheal extubation, and this circumstance will worsen airway compromise. In such a state, re-establishing the airway can become life-threatening. We describe the preemptive identification, physiologic manifestations, and management of the supraglottic and subglottic obstruction exemplified by this case.

Exercise-induced laryngeal obstruction: natural history and effect of surgical treatment

The current follow-up study concerning the supraglottic type of exercise-induced laryngeal obstruction (EILO) was performed to reveal the natural history of supraglottic EILO and compare the symptoms, as well as the laryngeal function in conservatively versus surgically treated patients. A questionnaire-based survey was conducted 2–5 years after EILO was diagnosed by a continuous laryngoscopy exercise (CLE) test in 94 patients with a predominantly supraglottic obstruction. Seventy-one patients had been treated conservatively and 23 with laser supraglottoplasty. The questionnaire response rate was 70 and 100% in conservatively treated (CT) and surgically treated (ST) patients, respectively. A second CLE test was performed in 14 CT and 19 ST patients. A visual analogue scale on symptom severity indicated improvements in both the groups, i.e. mean values (± standard deviations) declined from 73 (20) to 53 (26) (P < 0.001) in the CT group and from 87 (26) to 25 (27) (P < 0.001) in the ST group. At follow-up, ST patients reported lower scores regarding current level of complaints, and higher ability to perform exercise, as well as to push themselves physically, all compared to CT patients (P < 0.001). CLE scores were normalized in 3 of 14 (21%) CT and 16 of 19 (84%) ST patients (Z = −3.6; P < 0.001). In conclusion, symptoms of EILO diagnosed in adolescents generally decreased during 2–5 years follow-up period but even more after the surgical treatment. Patients with supraglottic EILO may benefit from supraglottoplasty both as to laryngeal function and symptom relief. Level of evidence 2b, individual retrospective cohort study.

Should the clinical study on opioid-induced cough continue?

Since Bohrer et al. [1] reported in 1990 that administering fentanyl through a central venous catheter induces the cough reflex, it has become well-known that remifentanil and fentanyl used for inducing general anesthesia cause a cough in various types of clinical situations. This has led to many clinical studies [2-4] thus far, and the research paper of Yoo et al. [5] is also included in this group. The proposed mechanisms through which opioids induce a cough are as follows: (1) pulmonary chemoreflex resulting from stimulation of C-fiber receptors (J receptors) [1], (2) stimulation of irritant receptors (rapidly adapting receptors) from deformation of the tracheobrochial wall by tracheal smooth muscle constriction [6], (3) the release of histamine from lung mast cells [7], and (4) the sudden adduction of the vocal cords or supraglottic obstruction by soft tissue caused by opioid-induced muscle rigidity [8]. Based on these mechanisms, many efforts have been made to reduce the cough reflex induced by opioid agents, and it has been reported that terbutaline (a selective beta-2 agonist) [9], salbutamol [7], lidocaine [10], ephedrine [11], clonidine [12], ketamine [13], and dexamethasone [5] are effective in reducing fenanyl-induced cough (FIC) or remifentanil induced cough (RIC). However, Elcock [14] referred to the paper of Hung et al. [2] that was included in the 2010 volume of Anesthesia and raised the question whether fentanyl really induces a cough with such a high frequency (18-65%) in clinical settings. Also, he stated that his experience of using fentanyl clinically (administering 30 mg of propofol when administering 100 ug of fentanyl before inducing anesthesia) did not induce a cough, and that he was perplexed that research on fentanyl-induced cough continues, and that in actuality, it is not problematic except for pediatric patients. As a result, he asserted that it is meaningless to conduct studies on this phenomenon because, at least for adults, the commonly used dosage of fentanyl does not pose any actual problem. There are also recent reports that recommend not administering the medicine because FIC and RIC are temporary and the pre-treatment itself can cause problems [15]. Moreover, there are studies showing good results from adjusting the administration method of fentanyl and remifentanil so that their blood concentration levels increase gradually, because it is the sudden rise of their blood concentration levels that trigger the cough inducing mechanisms. There are also reports of reducing coughs by administering fentanyl slowly [16] or by administering a small amount in advance, so that there is not a sudden increase in concentration [2]. Also, there are studies that coughs are reduced by administering remifentanil in separate doses [17] and by limiting the peak plasma concentration when infusing remifentanil by TCI [18]. The paper of Ambesh et al. [3] that was published in the British Journal of Anesthesia in 2010 also reported significantly reduced cough (32% to 4%) induced by 2.5 ug/kg of fentanyl if a huffing maneuver was done before inducing anesthesia. Thus, fentanyl and remifentanil induced cough can be significantly reduced even without medicinal prevention. The continuous repetition of the same form of clinical study for more than 20 years seems meaningless even though I do not totally agree with Elcock's opinion. I have also published a paper [19] in 1996 reporting that administration of fentanyl to pediatric patients leads to high-dosage dependency and frequent coughs, and administering lidocaine in advance reduces coughs. In 2010 I published a paper about the impact of FIC on endotracheal intubation in pediatric patients [4]. Although many studies have been carried out over decades, the mechanism of FIC or of RIC has not yet been found. Therefore, I believe it is more useful shed light on why a sudden increase in blood concentration induces a cough, instead of conducting studies about reducing its clinical frequency.

Perioperative complications in children with Apert syndrome: a review of 509 anesthetics

To perform a retrospective, anesthesia case note review in children with Apert Syndrome. To identify perioperative complications in this group of patients. Apert syndrome is a rare autosomal dominant disorder characterized by craniosynostosis, craniofacial anomalies, and severe symmetrical syndactyly (cutaneous and bony fusion) of the hands and feet. Children with this syndrome require general anesthetics for a number of different operations and procedures. Our institution has records of 71 children with Apert syndrome. Analysis of their general anesthetic records was undertaken, and the incidence of perioperative complications was investigated. A retrospective case note review was performed on 61 children with Apert syndrome over a 14-year period. There were a total of 509 general anesthetics administered to these children during this period of time. There were a total of 31 perioperative respiratory complications occurring in 21 patients (6.1% of the total cases). Twenty-three of these complications were supraglottic airway obstruction (4.5% of total cases). We found there to be a low incidence of major perioperative major complications in this group of patients. Nevertheless, a significant proportion of these children have obstructive sleep apnoea and may develop supraglottic airway obstruction on induction and emergence from anesthesia due to the associated mid-face anatomical abnormalities.

A retropharyngeal-mediastinal hematoma with supraglottic and tracheal obstruction: The role of multidisciplinary airway management

A 77-year-old man suffered hypoxemic cardiac arrest by supraglottic and tracheal airway obstruction in the emergency department. A previously unknown cervical fracture had caused a traumatic retropharyngeal–mediastinal hematoma. A lifesaving surgical emergency tracheostomy succeeded. Supraglottic and tracheal obstruction by a retropharyngeal–mediastinal hematoma with successful resuscitation via emergency tracheostomy after hypoxemic cardiac arrest has never been reported in a context of trauma. This clinically demanding case outlines the need for multidisciplinary airway management systems with continuous training and well-implemented guidelines. Only multidisciplinary staff preparedness and readily available equipments for the unanticipated difficult airway solved the catastrophic clinical situation.

Pediatric Obstructive Sleep Apnea and Adenotonsillectomy

Pediatric Obstructive Sleep Apnea and Adenotonsillectomy

Pediatric Obstructive Sleep Apnea and Adenotonsillectomy

Pediatric Obstructive Sleep Apnea and Adenotonsillectomy

Subperiosteal Release of the Floor of the Mouth in Airway Management in Pierre Robin Sequence

Procedures to relieve airway obstruction in Pierre Robin sequence (PRS) include glossopexy, mandibular distraction, and tracheostomy. Previously, it has been suggested that the imbalance of the genioglossus insertion on the mandible could be responsible for the micrognathia, tongue elevation, and glossoptosis seen in PRS. We performed a retrospective study to determine the usefulness of subperiosteal release of the floor of the mouth in PRS with airway problems. Between 1991 and 2005, 14 consecutive patients with PRS were treated with subperiosteal release of the floor of the mouth performed at the British Columbia's Children's Hospital. There were 8 boys and 6 girls. Mean age at surgery was 15 weeks (range, 1-68 weeks). Postoperative follow-up ranged from 8 months to 13 years. Seven patients (4 boys and 3 girls) were successfully treated, and a tracheostomy was prevented. Fifty-five percent of the syndromic patients needed a tracheostomy, whereas 1 patient (33%) with isolated PRS needed a tracheostomy. The most common syndrome associated with PRS was Stickler syndrome. Five (72%) of the 7 patients who required a tracheostomy were boys. If conservative measures fail to relieve supraglottic airway obstruction seen in patients with PRS, a subperiosteal release of the floor of the mouth can be an effective intervention in certain patients. It is a simple intervention with few complications and little morbidity. More investigations are mandatory to precisely define patient characteristics ideal for this intervention.

Surgical treatment of exercise-induced laryngeal dysfunction

A method for combined ergo-spirometry and continuous laryngeal inspection during exercise, entitled continuous laryngoscopy exercise test (CLE-test) has been developed in order to study airway obstruction at the laryngeal level during exercise. The aim of the study was to apply the CLE-test on patients experiencing respiratory distress during exercise in order to reveal the usefulness of the CLE-test both as a diagnostic tool in the selection of patients for surgery and in evaluation of treatment effects postoperatively. Until now, 81 patients with a history of exercise-induced stridor have undergone the CLE-test. Ten of these patients were selected for surgical treatment based on the severity of symptoms and their motivation for treatment. All ten patients underwent endoscopic supraglottoplasty (ES), with laser incision in both aryepiglottic folds anterior to the cuneiform cartilages and removal of the mucosa around the top of the tubercles. Each patient was examined by the CLE-test before and 3 months after surgery. Eight patients felt subjectively that their breathing capacity during exercise was improved. When pre- and postoperative ergo-spirometry evaluations were compared, increased peak oxygen consumption was observed in four out of ten patients and better maximal minute ventilation in seven out of ten. Postoperative evaluation of the laryngeal images showed less prominent aryepiglottic folds. The typical adduction of the supraglottic structures concomitant with inspiratory stridor found preoperatively was not present in any of the patients during exercise postoperatively. The ES procedure is an efficient surgical treatment for exercise-induced laryngeal supraglottic obstruction and the CLE-test eases the selection of patients for surgery and facilitates the evaluation of treatment effects.

Perioperative Complications of Adenotonsillectomy in Children with Obstructive Sleep Apnea Syndrome

We evaluated the rate of complications experienced by children who undergo adenotonsillectomy for obstructive sleep apnea syndrome (OSAS), the safety of a standard anesthetic protocol for these children, and preoperative predictors of complications. Sixty-one children with OSAS, confirmed by polysomnography, and 21 children with recurrent tonsillitis were anesthetized using a standard protocol before adenotonsillectomy (ages 2-16 yr, ASA 1-3). The number of complications and medical interventions in the perioperative period were recorded and correlated with the presence and severity of OSAS. Children with OSAS had more respiratory complications per operation than non-OSAS children (5.7 vs 2.9, P < 0.0001). Supraglottic obstruction, breath holding, and desaturation on anesthetic induction and emergence were the most common complications. Increased severity of OSAS, low weight, and young age are correlated with an increased rate of complications. Medical intervention was necessary in more children with OSAS during recovery and emergence than in the non-OSAS group (17/61 vs 1/21, P < 0.05). Both groups of children had similar opioid requirements and time to discharge from the recovery room. These findings suggest that children with OSAS are at risk for respiratory complications after adenotonsillectomy, but that these complications do not prolong the time to discharge.

SUPRAGLOTTIC CLOSURE DURING INHALATION AS A CAUSE OF EPISODIC DYSPNEA ON EXERTION

INTRODUCTION: A forty-four year old woman was referred for refractory asthma characterized by fifteen years of variable dyspnea, worse on exertion and associated with audible wheezing. She had responded poorly to inhaled and oral glucocorticoids. Flexible rhinolaryngoscopy showed collapse of the arytenoids during sniff maneuver resulting in supraglottic airway obstruction. A diagnosis of laryngomalacia was made. The otorhinolaryngologists recommended resection of redundant aryepiglottic folds and cuneiform cartilages but the patient refused the procedure.