Supraglottic Structures Research Articles

A rare case of non-specific chronic supraglottic laryngitis in a young female: a comprehensive case report

Chronic non-specific supraglottic laryngitis is a rare clinical condition characterized by chronic inflammation of the supraglottic structures without any evidence of infection, granulomatous disease, autoimmunity or malignancy. This is a case report of a young female presenting with a long-standing history of voice change and dysphagia. Laryngoscopy revealed diffuse inflammation of the supraglottis. Thorough workup, including radiological investigations, blood tests, bronchoscopy and biopsy, ruled out any known etiology. She was thus diagnosed with non-specific chronic supraglottic laryngitis. The patient responded well to the long-term use of oral corticosteroids and immunosuppressant drugs. This study summarizes the clinical presentation, comprehensive investigations and management of chronic, non-specific supraglottic laryngitis.

Supraglottitis: An airway emergency

Supraglottitis is a life-threatening condition and refers to inflammation of the epiglottis and the surrounding supraglottic structures. Children usually present with only a swollen epiglottis, termed epiglottitis. Fortunately, the incidence of epiglottitis in children has declined following routine Haemophilus influenzae type B vaccination, but the incidence in adults has increased. Supraglottitis has a high morbidity and mortality from the associated risk of airway obstruction. Therefore, early recognition and urgent secondary care referral is paramount. However, the presentation of this condition can be subtle and differs between children and adults; this can lead to difficulties in diagnosis. This article will review the clinical presentation and management of supraglottitis, an important differential for acute sore throat and hoarse voice.

Bispectral Index versus the University of Michigan Sedation Scale in assessing sedation depth during pediatric drug-induced sleep endoscopy.

Bispectral Index (BIS) and University of Michigan Sedation Scale (UMSS) were two commonly used methods of monitoring the sedation depth, but their correlation was not clear. The purpose of this study is to ascertain if BIS correlates with UMSS in determining the sedation level during pediatric drug-induced sleep endoscopy (DISE). One-hundred children, aged 36-143 months, with ASA I~II grade, were enrolled. They were subject to general anesthesia for an elective adenotonsillectomy. Two drug regimens were used. After UMSS ≥ 3, the sites of airway obstructions were located by checking the supraglottic airway structures with a fibrous laryngoscope. UMSS scores, BIS values, electromyography (EMG), and signal quality indices (SQIs) were recorded at the pre-medication and pre-DISE baseline (T0), 5 min subsequent to medication administration but prior to DISE initiation (T1), 1 min after DISE was initiated (T2), 1 min after DISE was completed (T3), 1 min subsequent to tracheal intubation (T4), 1 min following extubation (T5), and 30 min past extubation (T6). There were strong correlations between BIS monitor readings and UMSS scores for total and two regimens. Kappa values revealed moderate agreement between BIS and UMSS for total and two regimens. The agreement rates were 67.47% for the total, 61.43% for Regimen 1, and 73.42% for Regimen 2, respectively. BIS correlates with UMSS in determining the sedation level during pediatric DISE for two regimens. BIS might serve as an appropriate indicator of sedation intensity when UMSS could not be used.

Features and Associated Comorbidities of Laryngomalacia in Saudi Arabia.

Laryngomalacia (LM) is defined as the collapse of supraglottic structures during inspiration, resulting in intermittent airflow impedance and associated stridor. LM is the most prevalent cause of congenital stridor in newborns. The aim of this study is to determine the features and associated comorbidities of LM in Saudi Arabia and to delineate the diagnostic and therapeutic measures used, based on the severity of the case and related comorbidities. This is a three-year retrospective study of children diagnosed with LM and treated in the pediatric otorhinolaryngology outpatient clinic at Maternity and Children Hospital, Dammam, Saudi Arabia, between January 2018 and January 2022. The inclusion criteria were patients with signs and symptoms of LM who are younger than 14 years old. The diagnosis of LM was based on clinical evaluation and confirmed by nasopharyngolaryngoscopy in awake patients and/or direct laryngoscopy and scoping under general anesthesia with spontaneous ventilation for dynamic evaluation. The Olney classification was used for the morphological classification of LM. The exclusion criteria were patients lost to follow-ups. Follow-up duration was two years minimum. A total of 52 patients were included in the study. Among the participants, females accounted for 71% and males accounted for 29% of cases. Our results were in accordance with the relevant literature, except for the higher prevalence of LM in full-term neonates who were found to account for 69.2% of the cases. Understanding the patterns and characteristics of breathing may help clinicians distinguish the noisy breathing of LM from other illnesses because infants are frequently misdiagnosed with these conditions.

Transoral Laser-Assisted Infrahyoid Supraglottic Laryngectomy for Selected Patients With Supraglottic Cancer.

Supraglottic laryngectomy has evolved from open to transoral endoscopic approaches with advancements in surgical techniques and instruments such as lasers, endoscopes, ultrasonic devices, and robotics. Transoral laser-assisted microsurgery has emerged as an effective treatment option, offering faster functional recovery and serving as an alternative to partial laryngectomy or non-surgical therapies. Traditional endoscopic supraglottic laryngectomy involves resection of both suprahyoid and infrahyoid supraglottic structures. However, in cases where the tumor is limited to the infrahyoid epiglottis, a new technique known as transoral laser-assisted infrahyoid supraglottic laryngectomy allows for tumor removal while preserving the suprahyoid epiglottis, aryepiglottic folds, and vallecula, ensuring optimal preservation of laryngopharyngeal function. This procedure enables patients to swiftly return to their daily routines with minimal complications. This article discusses the surgical technique, potential indications, and advantages and disadvantages of the new approach for infrahyoid epiglottic cancer.

Acute Epiglottitis Secondary to the Severe Acute Respiratory Syndrome Coronavirus 2: A Case Report.

Acute epiglottis is a rapidly progressive, potentially life-threatening infection causing inflammation of the epiglottis and adjacent supraglottic structures.- Since the introduction of the Haemophilus influenzae vaccine, the incidence of pediatric cases has decreased dramatically while adult instances have increased. Likewise, the etiology has changed considerably with the increasing prevalence of other causative bacterial and viral pathogens. We present a novel case of acute epiglottis secondary to infection with the severe acute respiratory syndrome coronavirus 2. This case report highlights the changing landscape of epiglottitis and the importance of airway assessment. Present-day epiglottitis differs greatly from our traditional understanding. Numerous etiologies beyond Haemophilus influenzae now afflict adults predominately. As a clinically significant, novel complication of coronavirus disease 2019, acute epiglottitis is a life-threatening airway emergency. Emergency physicians must maintain a high index of suspicion, especially given the evolving clinical landscape. Early airway assessment with nasopharyngolaryngoscopic is critical.

Acquired laryngomalacia as a cause of post-extubation stridor and extubation failure following craniotomy: a case report

BackgroundLaryngomalacia is a dynamic airway condition characterized by flaccid laryngeal tissue and inward collapse of supraglottic structures during inspiration. Although it may cause airway obstruction and requires careful management, there have been few reports regarding laryngomalacia after surgery. We report a case of adult-onset laryngomalacia occurred after craniotomy requiring reintubation.Case presentationA 21-year-old man was admitted to the ICU after craniotomy for a cerebellopontine angle tumor. He developed severe stridor immediately after extubation on the postoperative day 2 and required reintubation. On the postoperative day 5, similar episode occurred following re-extubation and fiberoptic laryngoscopy revealed a collapsed epiglottis and left arytenoid into the glottis. A diagnosis of laryngomalacia was made, and he underwent tracheostomy. Laryngomalacia had completely improved; however, bilateral vocal cord paralysis was detected 2 weeks later.ConclusionsAcquired laryngomalacia should be considered as a possible mechanism of the airway symptoms in a patient with neurological dysfunction.

Visual-perceptive assessment of glottic characteristics of vocal nodules by means of high-speed videoendoscopy

ObjectiveVisual-perceptive assessment of glottic characteristics of vocal nodules by means of high-speed videoendoscopy. MethodsDescriptive observational research with convenience sampling of five laryngeal videos of women with an average age of 25 years. The diagnosis of vocal nodules was defined by two otolaryngologists, with 100% intra-rater agreement and 53.40% inter-rater agreement and five otolaryngologists as judge assessed the laryngeal videos based on an adapted protocol. The statistical analysis calculated measures of central tendency and dispersion, as well as percentage. The AC1 coefficient was used for agreement analysis. ResultsIn high-speed videoendoscopy imaging, vocal nodules are characterized by amplitude of the mucosal wave and muco-undulatory movement with magnitude between 50% and 60%. Non-vibrating segments of vocal folds are scarce, and the glottal cycle does not show a predominant phase, it is symmetric and periodic. Glottal closure is characterized by the presence of a mid-posterior triangular chink (double chink or isolated mid-posterior triangular chink), without movement of supraglottic laryngeal structures, with irregular contour of the free edge of vocal folds, which are vertically on-plane. ConclusionVocal nodules present mid-posterior triangular chink and irregular free edge contour. Amplitude and mucosal wave were partially reduced. Level of evidenceLevel 4 (Case-series).

Prevalence of Dysphonia in Metal Singers and the Impact of Vocal Education: A Subjective Analysis

On average, the prevalence of subjectively indicated dysphonia in singers is higher than in the general population. When using extreme vocal techniques supraglottic structures are involved to protect the vocal folds. Most of the metal singers learn this specific singing style autodidactically. Vocal training can have a positive effect on the voice and prevent voice problems. The aim of the study was to find out the prevalence of dysphonia in metal singers and the impact this has on the profession or the vocal education. The subjects had to fill out an online questionnaire including two validated and standardized questionnaires about the speaking and singing voice: The short version of the Voice Handicap Index (VHI 12) and the Singing Voice Handicap Index (SVHI). The prevalence of dysphonia in metal singers is 12.2%. 9 out of 74 participants showed an increased (S)VHI score. 6 of these participants learned singing autodidactically. No dysphonia was found in any singer who sings full-time or studied singing. The correlation between education or profession and dysphonia was statistically not significant. More women than men studied or took singing lessons. This difference was statistically significant. The prevalence of 12.2% in our study is quite low and contrary to our assumption. We can assume, that a vocal education for the metal singing style is useful but not mandatory and the number of persons with dysphonia through metal singing is low. A healthy vocal technique does not necessarily have to be the result of voice lessons.

Extreme Vocals—A Retrospective Longitudinal study of Vocal Health in 20 Professional Singers Performing and Teaching Rough Vocal Effects

Rough vocal effects, extreme, or extended vocal techniques to sound intentionally hoarse or rough are an integral part of many genres and styles, and research has recently demonstrated the involvement of supraglottic narrowing and vibrations to produce such sounds. The vocal health of singing with rough vocal effects is poorly documented, especially in a longitudinal manner, while much vocal pedagogy continuously treats the sounds as harming to or dangerous for the vocal mechanism. To longitudinally investigate the vocal health of professional singers who perform the five rough-sounding vocal effects Distortion, Growl, Grunt, Rattle, and Creaking as part of their singing and teaching. Twenty singers underwent nasoendoscopic examination, filled in SVHI questionnaires, and were assessed by GRBAS with a 14-year interval in a retrospective longitudinal study (from 2007 to 2021). Endoscopic materials were assessed by Reflux Finding Score and a hybrid version of the Stroboscopy Rating Scale. Singers presented at initiation of study with an average SVHI of 9.2 (±9), which decreased at time of follow up 14 years later to an average of 5.12 (±6). Laryngeal assessments (RFS and SRS) revealed low averages at initiation of study as well as at conclusion of the study with only small fluctuations in averages, with findings mainly relating to arytenoid asymmetry. The participating singers perform and teach rough vocal effects continually and present with healthy laryngeal mechanisms and within-normal SVHI and GRBAS scores. The findings suggest that controlled supraglottic narrowing and techniques to allow for supraglottic structures to engage in vibration as an additional noise source can be performed sustainable and in a healthy manner if performed with correct vocal technique.

Supraglottic laryngectomy for endoscopic resection: proposal of a new classification

<p class="abstract">Proposal of a new classification, which includes six types of resections, for supraglottic laser surgical treatment. Our classification defines precisely Type Ia excision as an en bloc procedure. Aside, the lateral supraglottic resections are described in detail, with type Ib, II and III modalities, which encompass excision of lateral supraglottic structures and partial paraglottic space excision, due to the potential for extension to this space present on laterally located tumors. Type IV resection refers to a complete supraglotic laryngectomy, which addresses the preepiglottic spread potential of midline supraglottic lesions. Type Va resection or arytenoidectomy is introduced, leaving types Vb and Vc as previously described cordectomies. A new concept of palliative procedures types VIa and VIb is presented, according to invasion to supraglottic structures and/or tongue base extension in T3-T4 lesions. A classification should be understandable, reproducible and easy to interpret, so that it facilitates comparison of results and potentially translates into better oncologic outcomes. Laser resection of the supraglottis must not be consider curative for all patients, objective are different according to the stage, so the present classification include: Partial,, Extended and Palliative Delbulking Resection.</p>

Extreme Vocal Effects Distortion, Growl, Grunt, Rattle, and Creaking as Measured by Electroglottography and Acoustics in 32 Healthy Professional Singers

SummaryVocal effects - also called extreme or extended vocal techniques - with the intention to sound hoarse or rough are widely used as part of many genres and styles of singing, yet scarcely documented in research. Physiological studies detail the involvement of supraglottic structures for the production of vocal effects, yet the acoustic impact of such involvement has not been documented systematically across phonation types. PurposeTo report acoustic measurements and electroglottography-specific measurements for the five rough-sounding vocal effects Distortion, Growl, Grunt, Rattle, and Creaking across phonation types to demonstrate differences between notes with and without vocal effects added. MethodsThirty-two professional singers and singing teachers produced sustained vowels in each of the four vocal modes with alternations of adding and removing the vocal effects. The singers were recorded with a microphone at a constant distance as well as with EGG. ResultsThe vocal effects Distortion, Growl, Grunt, Rattle, and Creaking impact the acoustic spectra in separate and systematic ways across genders and phonation types. Each vocal effect impacted the spectrum in specific and particular frequency regions between 0 and 3.5 KHz as well as in higher partials after 12 kHz with statistical significance. EGG-waveforms were un-impacted by most of the vocal effects produced using supraglottic sound sources, whereas Grunt and Creaking conditions did impact EGG-waveform signals, though not consistently between participants. EGG measures confirmed sustained and unchanged Qx and Fx for most conditions, with statically significant changes in noise measurements Harmonic-to-Noise Ratio, Normalised Noise Energy, Relative Average Perturbation, and Cepstral Peak Prominence, despite Sound Pressure Level differing significantly only for a few specific conditions. Singers scored an average of 5,95 on Voice Handicap Index questionnaires and were all reportedly healthy. ConclusionsVocal effects added to phonation produce specific increases and specific decreases in particular frequency regions in a systematic way and can be produced in a healthy and sustainable manner, as measured by Voice Handicap Index. Vocal effects can be added to different phonation types with differing acoustic output and singers were able to sustain and control involvement of the supraglottic sound source(s) independently of phonation type.

Laryngomalacia in the Premature Neonate.

Laryngomalacia is the most common cause of stridor in newborns. Affected patients may present with noisy breathing, a classic high-pitched inspiratory stridor that worsens with feeding. While the exact etiology remains unclear, the condition is characterized by softening of the supraglottic structures, including the epiglottis, aryepiglottic folds, and arytenoid cartilages. The condition is most often self-limited and requires expectant management. However, in some infants, severe disease, including failure to thrive or respiratory distress, may require medical or even surgical intervention. When caring for premature neonates, special care is required to evaluate for synchronous airway lesions.

Anaesthetic Management of an Infant with Laryngeomalacia and CHD Scheduled for Rigid Tracheobronchoscopy

Introduction: Laryngomalacia is defined as collapse of supraglottic structures during inspiration. It is the most common laryngeal disease of infancy and cause of stridor in newborns. Case Report: A 17 days old child (2.75kgs) with congential laryngomalacia was scheduled for rigid tracheobronchoscopy. Child had a history of recurrent lower respiratory tract infection which resolved with intravenous antibiotics and steroids. On auscultation he had no adventitious sounds when quiet but added sounds were heard when he cried. Echocardiography showed CHD with situs solitus levocardia with 4mm ASD and 2mm PDA with dilated RA/RV. The child was administered atropine, midazolam, atracurium and ketamine. Maintainence with sevoflurane . During rigid bronchoscopy we provided adequate analgesia and sedation without clinically significant hemodynamic or respiratory adverse effects. Conclusion: In summary we noted that ketamine provided a reliable and effective method of sedating infants undergoing a rigid bronchoscopic examination in spontaneous ventilating conditions and noted no clinically significant haemodynamic or respiratory problems. When these patients do present, their care is likely to be complex and challenging. As such , a multidisciplinary approach should be adopted throughout their period of care.

Relationship between laryngomalacia and sleep-related breathing disorders in infants with brief resolved unexplained events

Introduction: Brief resolved unexplained events (BRUE) occur during infancy. It is characterized by one or more symptoms, including skin color change, shortness of breath and unresponsiveness. Laryngomalacia is the most frequent cause of stridor in infants and results in the collapse of the supraglottic structures during inspiration and intermittent obstruction of the upper airways. To our knowledge, the relationship between BRUE and laryngomalacia has been little investigated. Methods: The medical records of 448 children (age < 12 months) treated for BRUE between July 2011 and March 2018 and followed up until March 2020 were retrospectively reviewed. Endoscopic evaluation was performed using a flexible fibrolaryngoscope. All patients underwent a brief polysomnography and 24-h cardiorespiratory monitoring. Cardiorespiratory and oxygen saturation monitoring was continued at home; 94% of patients underwent follow-up. Results: Laryngeal fiberoptic endoscopy revealed laryngomalacia in 11% of children with a clinical history of BRUE. Laryngomalacia was associated with obstructive/mixed apnea in 67%. Home cardiorespiratory monitoring showed a gradual reduction in the number of respiratory events during follow-up and complete resolution of laryngomalacia in 88% of patients. Conclusions: This is the first report that showed follow-up data from cases of BRUE with laryngomalacia. The improvement in laryngomalacia alone, although not complete, was sufficient to improve obstructive events.

A Case of Laryngeal Granulomatosis with Polyangiitis Simulating Acute Epiglottitis

A 41-year-old woman, presented with sore throat and dyspnea of 1 week’s duration. Fiberoptic laryngoscopy showed a swollen edematous epiglottis. Because the patient developed stridor and shortness of breath, tracheostomy was performed to secure the airway. Contrast-enhanced computed tomography (CT) showed high-density areas in the epiglottis, base of the tongue, and aryepiglottic folds. The patient was positive for proteinase 3 (PR3)-antineutrophil cytoplasmic antibody (ANCA, 4.9 U/ml) and negative for myeloperoxidase (MPO)-ANCA. A histo-pathological examination of an epiglottis biopsy specimen showed geographic necrotizing granuloma with a few scattered multinucleated giant cells. Transmural inflammation, luminal occlusion, and vessel disruption were observed on elastic staining. Based on these findings, the patient was diagnosed with granulomatosis with polyangiitis (GPA). Two months after the patient started therapy with high-dose steroids and cyclophosphamide, the epiglottic swelling improved. The level of PR3-ANCA returned to the normal range two months after starting treatment. Subglottic stenosis is reportedly a common clinical feature of GPA. Although the involvement of supraglottic structures, including the epiglottis, is rare in GPA, clinicians should include GPA in the differential diagnosis of a life-threatening airway obstruction.

Kawasaki disease presenting with hoarseness: A multinational study of the REKAMLATINA network.

Recently, hoarseness affecting the supraglottic structure has been reported in Kawasaki disease (KD). The objective of this study was to characterize the frequency of hoarseness in acute KD patients in Latin America. We used prospective data from the multinational Red de Enfermedad de Kawasaki en America Latina (REKAMLATINA) network. A total of 865 patients from 20 countries were enrolled during the 3 year study period. Data on hoarseness were available in 858 (99.2%) patients. The clinical and laboratory characteristics between hoarse and non-hoarse KD were compared. Hoarseness was documented in 100 (11.6%) patients. Hoarse patients were younger than those with KD without hoarseness (median age 18 vs 26months; P=0.002) and presented with lower hemoglobin (10.7g/dL vs 11.3g/dL; P=0.040) and hematocrit levels (32% vs 33%, P=0.048). Hoarseness was found to be prevalent as a presenting sign of acute KD in younger children. Anemia may indicate the presence of active inflammation.

Fluid-structure-acoustic interactions in an ex vivo porcine phonation model.

In the clinic, many diagnostic and therapeutic procedures focus on the oscillation patterns of the vocal folds (VF). Dynamic characteristics of the VFs, such as symmetry, periodicity, and full glottal closure, are considered essential features for healthy phonation. However, the relevance of these individual factors in the complex interaction between the airflow, laryngeal structures, and the resulting acoustics has not yet been quantified. Sustained phonation was induced in nine excised porcine larynges without vocal tract (supraglottal structures had been removed above the ventricular folds). The multimodal setup was designed to simultaneously control and monitor key aspects of phonation in the three essential parts of the larynx. More specifically, measurements will comprise (1) the subglottal pressure signal, (2) high-speed recordings in the glottal plane, and (3) the acoustic signal in the supraglottal region. The automated setup regulates glottal airflow, asymmetric arytenoid adduction, and the pre-phonatory glottal gap. Statistical analysis revealed a beneficial influence of VF periodicity and glottal closure on the signal quality of the subglottal pressure and the supraglottal acoustics, whereas VF symmetry only had a negligible influence. Strong correlations were found between the subglottal and supraglottal signal quality, with significant improvement of the acoustic quality for high levels of periodicity and glottal closure.

OROPHARYNGEAL SQUAMOUS CELL CARCINOMA TREATED CONCURRENTLY WITH CETUXIMAB: A CASE REPORT OF INTOLERANCE TO CISPLATIN IN YOUNG AGE

Squamous cell carcinoma of the oropharynx is a common case of head and neck cancer related to human papillomavirus. We present a case of moderately (G2) differentiated squamous cell carcinoma, which responded well to concurrent radiotherapy with cetuximab after intolerance of cisplatin. A 37-year-old woman referred to our hospital for a locally advanced cancer of the base of tongue. Physical examination revealed an ulcerative tumor with spread to the supraglottic structures, and swelling of the right side cervical lymph node at group IIA. The histological diagnosis from a biopsy specimen was moderately differentiated p16 positive squamous cell carcinoma. The patient underwent cisplatin-based concurrent chemoradiotherapy. Two – three weeks after receiving an intravenous cisplatin dose 100 mg/m 2 for the first day of chemorradiation, the patient presented with profound bilateral sensorineural hearing loss. The cisplatin-based chemotherapy had changed to alternative agent. The patient continuously underwent concurrently radiation with cetuximab without the break of radical radiotherapy course. The patient experienced partial recovery of hearing after radical treatment of cancer. Complete clinical and radiological response of oropharyngeal squamous carcinoma was achieved. Conclusions. Toxicity with only one standard dose of cisplatin can be profound also in young age. This risk should be addressed when counseling patient prior to initiation of treatment. In case of platinum ineligibility, replacing cisplatin with less toxic agent cetuximab may be taken into consideration for p16 positive carcinoma of the oropharynx.

Phagosyncope: an unusual presentation of airway malfunction due to acquired laryngomalacia in an elderly Indian male

&lt;p&gt;Acquired laryngomalacia is an uncommon entity in adults. It may often be misdiagnosed, under-reported or confused with respiratory diseases such as bronchial asthma. The exact pathogenesis of acquired laryngomalacia remains poorly understood, although many at-risk groups have been identified. High pitched inspiratory stridor which worsens with physical exertion is often encountered in patients. Predominantly being a mechanical issue, wherein supraglottic structures occlude the airway, causing respiratory distress and hypoventilation, adult laryngomalacia may cause choking episodes. In the elderly, where mucosal laxity and poor neuromuscular control may be encountered, a possibility of this illness must be kept in mind in those presenting with respiratory symptoms. Supraglottoplasty remains the best mode of treatment currently and has a high success rate. The authors report a case of acquired laryngomalacia in an elderly male, who presented with an unusual cluster of complaints. He underwent detailed evaluation for confirmation of his diagnosis and underwent surgical correction, which ameliorated his condition.&lt;/p&gt;