Age-related changes in the hyoepiglottic ligament: functional implications based on histopathologic study

Types of Epiglottic Collapse in Breathing Sleep Disorder and Their Impact in Clinical Practice

Introduction  Obstructive sleep apnea (OSA) is a severe form of sleep-disordered breathing (SDB) that is strongly correlated with comorbidities, in which epiglottic collapse (EC) and other contributing factors are involved. Objectives  To evaluate the occurrence of EC in OSA patients through drug-induced sleep endoscopy (DISE) and to determine the factors contributing to EC. Methods  A retrospective study of 37 adult patients using medical history. Patients were assessed for laryngopharyngeal reflux (LPR) and lingual tonsil hypertrophy (LTH) using reflux symptom index and reflux finding score (RFS); for OSA using polysomnography, and for airway collapse through DISE. An independent t -test was performed to evaluate risk factors, including the involvement of three other airway structures. Results  Most EC patients exhibited trap door epiglottic collapse (TDEC) (56.8%) or pushed epiglottic collapse (PEC) (29.7%). Lingual tonsil hypertrophy, RFS, and respiratory effort-related arousal (RERA) were associated with epiglottic subtypes. Laryngopharyngeal reflux patients confirmed by RFS (t(25) = -1.32, p  = 0.197) tended to suffer PEC; LTH was significantly associated (X2(1) = 2.5, p  = 0.012) with PEC (odds ratio [OR] value = 44) in grades II and III LTH patients; 11 of 16 TDEC patients had grade I LTH. Pushed epiglottic collapse was more prevalent among multilevel airway obstruction patients. A single additional collapse site was found only in TDEC patients. Conclusion  Laryngopharyngeal reflux causes repetitive acid stress toward lingual tonsils causing LTH, resulting in PEC with grade II or III LTH. Trap door epiglottic collapse requires one additional structural collapse, while at least two additional collapse sites were necessary to develop PEC. Respiratory effort-related arousal values may indicate EC.

Histological observations of age-related changes in the epiglottis associated with decreased deglutition function in older adults

Although the epiglottis plays a vital role in deglutition, histological studies of the epiglottis and surrounding ligaments associated with swallowing dysfunction are limited. Therefore, we performed histological observations to clarify age-related changes in the morphological characteristics of the epiglottis and surrounding structures. Tissue samples comprising the epiglottis and surrounding structures were collected from corpses that were both orally fed and tube-fed during their lifetimes. Following hematoxylin and eosin, Elastica Van Gieson, and immunohistochemical staining procedures, the chondrocytes, connective tissue, and glandular tissue were observed under the epiglottis epithelium, and intervening adipose tissue was observed in the surrounding area. Fatty degeneration of acinar cells was also observed in the glandular tissue, possibly because of aging. Bundles of elastic fibers were present around the vascular wall in the peri-epiglottic ligament, but some were reduced. Furthermore, large amounts of collagen fibers ran toward and through the cartilage, whereas the mesh-like elastic fibers stopped in front of the cartilage. Microfibrils considered to be oxytalan fibers, which are thinner and shorter than elastic fibers, were observed around the vascular wall and in the fiber bundles. Age-related changes included connective tissue fibrosis shown by the large amount of collagen fibers, atrophy of salivary glands, and an accompanying increase in adipose tissue. Regarding stretchability and elasticity, the elastic fibers may have an auxiliary function for laryngeal elevation during deglutition. This suggests that disuse atrophy of the laryngeal organs with or without oral intake might reduce the amount of elastic fiber in older adults.

The effect of CPAP on the upper airway and ventilatory flow in patients with obstructive sleep apnea

BACKGROUND

Continuous positive airway pressure (CPAP) is the mainstay of treatment for obstructive sleep apnea (OSA). However, data about its effect on the upper airway, especially the epiglottis, are scarce. The aim of this study was to investigate the changes in upper airway dimensions and inspiratory flow in response to incremental pressure levels.

METHODS

This is a secondary analysis of a prospective clinical trial in which patients with moderate to severe OSA underwent drug-induced sleep endoscopy with simultaneous recordings of flow and mask pressure. CPAP was titrated in small increments. For each pressure level a representative 3-breath segment was selected to determine specific flow features. The corresponding endoscopic footage was reviewed to assess the degree of upper airway collapse in a semi-quantitative manner.

RESULTS

A total of 214 breath segments were obtained from 13 participants (median [Q1-Q3]; apnea-hypopnea index, 24.9 [20.1-43.9] events/h; body mass index 28.1 [25.1-31.7] kg/m²). CPAP significantly increased cross-sectional dimensions of the soft palate, lateral walls and tongue base, but not of the epiglottis, and induced epiglottis collapse in one subject. Increased pressure improved peak inspiratory flow and median ventilation in all patients, even in the presence of persistent epiglottis collapse.

CONCLUSION

CPAP does not effectively address epiglottis collapse in patients with OSA. However, it normalizes inspiratory flow regardless of its effect on the epiglottis. This clinical trial was registered on January 18th, 2020 on ClinicalTrials.gov with identifier NCT04232410.

A Newly Discovered Tendon Between the Genioglossus Muscle and Epiglottic Cartilage Identified by Histological Observation of the Pre-Epiglottic Space

Epiglottic retroversion is difficult to explain anatomically. One reason is inadequate structural identification of the ligaments in the submucosal tissue anterior to the epiglottis (pre-epiglottic space, PES). Although studies have shown that tongue root movement plays a role in epiglottic retroversion, few morphological reports have investigated the attachment of the lingual muscles to the epiglottis. This study reconstructed the fiber structure of the PES by comprehensively analyzing fiber alignment in the PES focusing on the hyoepiglottic ligament, which runs between the lingual muscles and the epiglottis. Gross and microscopic observations of the submucosal structures from the tongue to the larynx of 20 cadavers (10 men, 10 women; mean age 79 years) were performed. A tendon continuing from the posterior part of the genioglossus muscle and attaching to the center of the epiglottic cartilage was identified in the midline area of the epiglottis. We named this tendon the glossoepiglottic tendon. In contrast, the hyoepiglottic ligament is found between the hyoid bone and the epiglottis and is attached from the lateral margin of the epiglottic cartilage to its base. Furthermore, the glossoepiglottic tendon consists of a high-density fiber bundle that is thicker than the hyoepiglottic ligament. These results show that the conventional hyoepiglottic ligament has a two-layer structure consisting of an upper fiber bundle connected to the genioglossus muscle and a lower fiber bundle connected to the hyoid bone. Sustained contraction of the posterior part of the genioglossus muscle therefore places the epiglottis under persistent traction, suggesting that its relaxation may cause epiglottic retroversion.

Dual Staged Supraglottoplasty for the Treatment of Trapdoor Epiglottis with Underlying Neurodegenerative Disease-Case report and Review of literature

To describe the technique and outcome of a novel dual staged supraglottoplasty for the treatment of neurological induced adult onset laryngomalacia. A 55 year old male had a diagnosed neurodegenerative disorder with suspected Pompe's disease associated with Trap door epiglottis and proximal myopathy.This was complicated with emergency airway distress and subsequent tracheostomy.Trap-door epiglottis (also known as adult-onset laryngomalacia) associated with neurodegenerative disorders constitute a surgical challenge as it is often coupled with failure of tracheostomy decannulation when present. The patient underwent a novel dual staged endoscopic supraglottoplasty whereby an initial stage of epiglottopexy and submucosal diathermy was made at the vallecula.This was then followed by an interval of 6 weeks whereby a partial epiglottotectomy was made at the upper 3rd of the epiglottis and reduction of lingual tonsils was done using radiofrequency ablation.Trachesotomy was decannulated 1 month after the second stage procedure and his airway remains asymptomatic after 1 year of surgical treatment. This case report describes the success of tracheostomy decannulation after a novel dual staged supraglottoplasty for adult onset laryngomalcia (also known as trap-door epiglottis) .

Resuscitation of the Critically Ill Older Adult

In 30 years, adults 65 and older will represent 20% of the US population, with increased medical comorbidities leading to higher rates of critical illness and mortality. Despite significant acute illness, presenting symptoms and vital sign abnormalities may be subtle. Resuscitative guidelines are a helpful starting point but appropriate diagnostics, bedside ultrasound, and frequent reassessments are needed to avoid procrustean care that may worsen outcomes. Baseline functional status is as important as underlying comorbid conditions when prognosticating, and the patient's personal wishes should be sought early and throughout care with clear communication regarding prospects for immediate survival and overall recovery.

Electromyographic activation patterns during swallowing in older adults

Age-related weakness due to atrophy and fatty infiltration in oropharyngeal muscles may be related to dysphagia in older adults. However, little is known about changes in the oropharyngeal muscle activation pattern in older adults. This was a prospective and experimental study. Forty healthy participants (20 older [> 60 years] and 20 young [< 60 years] adults) were enrolled. Six channel surface electrodes were placed over the bilateral suprahyoid (SH), bilateral retrohyoid (RH), thyrohyoid (TH), and sternothyroid (StH) muscles. Electromyography signals were then recorded twice for each patient during swallowing of 2 cc of water, 5 cc of water, and 5 cc of a highly viscous fluid. Latency, duration, and peak amplitude were measured. The activation patterns were the same, in the order of SH, TH, and StH, in both groups. The muscle activation patterns were classified as type I and II; the type I pattern was characterized by a monophasic shape, and the type II comprised a pre-reflex phase and a main phase. The oropharyngeal muscles and SH muscles were found to develop a pre-reflex phase specifically with increasing volume and viscosity of the swallowed fluid. Type I showed a different response to the highly viscous fluid in the older group compared to that in the younger group. However, type II showed concordant changes in the groups. Therefore, healthy older people were found to compensate for swallowing with a pre-reflex phase of muscle activation in response to increased liquid volume and viscosity, to adjust for age-related muscle weakness.

Use of volume controlled vs. pressure controlled volume guaranteed ventilation in elderly patients undergoing laparoscopic surgery with laryngeal mask airway

Background

The peak inspiratory pressure (PIP) is crucial in mechanical ventilation with supraglottic airway device (SAD). Pressure-controlled ventilation volume-guaranteed (PCV-VG), delivering a preset tidal volume with the lowest required airway pressure, is being increasingly used during general anesthesia. In this study, we compared respiratory mechanics and circulatory parameters between volume-controlled ventilation (VCV) and PCV-VG in elderly patients undergoing laparoscopic surgery using the laryngeal mask airway supreme (LMA).

Methods

Eighty participants scheduled for laparoscopic surgery were enrolled in this prospective, randomized clinical trial. The participants were randomly assigned to receive VCV or PCV-VG. PIP, dynamic compliance (Cdyn) and mean inspiratory pressure (Pmean) were recorded at 5 min after induction of anesthesia (T1), 5 min after pneumoperitoneum(T2), 30 and 60 min after pneumoperitoneum (T3 and T4). Data including other respiratory variables, hemodynamic variables, and arterial blood gases were also collected. The difference in PIP between VCV and PCV-VG was assessed as the primary outcome.

Results

PIP was significantly lower at T2, T3, and T4 in both groups compared with T1 (all P <  0.0001), and it was significantly lower in the PCV-VG group than the VCV group at T2, T3, and T4 (all P <  0.001). Cydn was decreased at T2, T3, and T4 in two groups compared with T1 (all P <  0.0001), but it was higher in PCV-VG group than in VCV group at T2, T3, and T4 (all P <  0.0001). There were on statistically significant differences were found between the groups for other respiratory and hemodynamic variables.

Conclusion

In elderly patients who underwent laparoscopic surgery using an LMA, PCV-VG was superior to VCV in its ability to provide ventilation with lower peak inspiratory pressure and greater dynamic compliance.

Differential diagnosis and management of adult-onset laryngomalacia

OBJECTIVE

Adult-onset laryngomalacia is a rare clinical entity that has been infrequently reported. This study aims to evaluate the clinical presentation, diagnosis, and management of adult-onset laryngomalacia through literature review and report of a case.

METHODS

PubMed and Google Scholar databases were queried for articles published from 1960 to 2019 including only patients aged 18 years and older. Included keywords were: 'laryngomalacia', 'adult laryngomalacia', 'acquired laryngomalacia', 'idiopathic laryngomalacia', 'laryngeal obstruction', 'floppy epiglottis', 'floppy epiglottis', and 'epiglottis prolapse'. Data extracted from literature included clinical presentation, diagnostic workup, surgical management, and follow-up care.

SOURCES

PubMed and Google Scholar.

RESULTS

A total of 21 articles reported 41 cases of adult-onset laryngomalacia. Within these cases, 5 etiologies were identified: neurologic (n = 14), exercise-induced (n = 9), post-operative (n = 7), idiopathic (n = 7), and age-related (n = 4) laryngomalacia. Anterior prolapse of arytenoids and aryepiglottic folds was the most common laryngoscopic finding (n = 21), followed by posterior epiglottic prolapse (n = 20). Management included supraglottoplasty (n = 14), epiglottidectomy (n = 8) or epiglottopexy (n = 2). Neurologic etiology required tracheotomy more often than the other etiologies (n = 5, 36% vs. 15%). Three patients were managed expectantly without surgical intervention and reported symptom resolution.

CONCLUSION

Adult laryngomalacia is a rare diagnosis comprising a spectrum of disease. This diagnosis may be overlooked, but association with neurologic injury or trauma should encourage consideration. In comparison to pediatric laryngomalacia, patients often require surgical intervention. Surgical decision is based on the direction of supraglottic collapse, where supraglottoplasty and partial epiglottidectomy are effective interventions.

LEVEL OF EVIDENCE

N/A.

Epiglottis shape as a predictor of obstruction level in patients with sleep apnea

PURPOSE

Despite a broad range of diagnostic methods, identifying the site of obstruction in the upper respiratory tract in patients with obstructive sleep apnea is not always simple and straightforward. With regard to this problem, we present our observations about the specific shape of the epiglottis in patients with obstruction at the level of the tongue base and/or epiglottis.

METHODS

One hundred and forty consecutive drug-induced sleep endoscopy (DISE) video recordings of patients with polygraphy-verified obstructive sleep apnea were analyzed by three independent observers. We compared the levels of obstruction using the VOTE classification and the shape of the epiglottis, both as seen during the DISE investigation and in the awake state. We have calculated the interrater reliability for VOTE classification results and epiglottis shape evaluation by three different observers.

RESULTS

Out of 140 patients, there were 52 (37.1%) with a flat epiglottis. Within this group, there were only 3 (6%) cases in which obstructions at the tongue base and/or epiglottis level were not found. In the group with normally convex and omega-shaped epiglottis, obstruction at the tongue base level was observed in 28 patients (31.8%); obstruction at the epiglottis level was observed in 5 patients (5.7%); and obstruction at both the epiglottis and tongue base level was observed in 3 patients (3.4%). Interrater reliability for VOTE classification was poor for V (ICC = 0.414) and good for O (ICC = 0.824), T (ICC = 0.775), and E (ICC = 0.852). Additionally, interrater reliability was excellent for epiglottis shape (ICC = 0.912).

CONCLUSION

In patients with obstructive sleep apnea, examinations in the awake state and drug-induced sleep endoscopy both showed that in most cases of obstruction at epiglottis and/or tongue base, the epiglottis was flat, i.e., lacking the typical anterior convexity in its upper part. We assume that the change of its shape is a result of degeneration of suspensory apparatus that maintains the shape of the epiglottis and holds it in its position. This could contribute to the better identification of patients with a narrowing at this level, and in turn to better decisions regarding the choice of the most suitable treatment.

Hyoepiglottic ligament collagen and elastin fiber composition and changes associated with aging

OBJECTIVE

The epiglottis may contribute to upper airway obstruction in approximately 10% of patients with obstructive sleep apnea. Clinical experience indicates that older patients may be more likely to have epiglottis-related obstruction. This study was designed to examine tissue characteristics of the hyoepiglottic ligament as a possible factor in epiglottis-related obstruction based on previous research suggesting that older adults have fewer collagen, elastin, and muscle fibers in the hyoepiglottic ligament.

METHODS

This is a cross-sectional study of 25 human cadaver hyoepiglottic ligaments. Specimens were stained using Masson's trichrome and Picrosirius red for collagen fibers and with Verhoeff-Van Gieson for elastin fibers. Percentage of collagen and elastin fiber staining for each specimen was calculated and averaged over three regions of each ligament section. Regression analysis was used to determine the association between age, smoking history, and collagen and elastin composition of the hyoepiglottic ligament.

RESULTS

The average age of the specimens was 68.4 ± 15.1 years (range 30-90 years). Increasing age was associated with a lower percentage of collagen and elastin fibers. When accounting for tobacco use, each 1-year increase in age was associated with a 0.53% decrease in Masson's trichrome staining (P = 0.004), a 0.35% decrease in Picrosirius red staining (P = 0.023), and a 0.33% decrease in Verhoeff-Van Gieson staining (P = 0.008).

CONCLUSION

Increasing age is associated with decreases in the collagen and elastin content of the hyoepiglottic ligament.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:1245-1248, 2018.

Repetitive postoperative extubation failure and cardiac arrest due to laryngomalacia after general anesthesia in an elderly patient: a case report

The authors report a case involving an elderly patient who experienced repetitive perioperative cardiac arrest caused by laryngomalacia. The patient underwent surgery under general anesthesia; however, 2 h after initial extubation, he experienced cardiopulmonary arrest. Return of spontaneous circulation was achieved by immediate resuscitation. Four hours later, a second extubation was performed without any neurological complications. However, 2 h later, he experienced cardiopulmonary arrest again. Immediately after the third extubation, 12 h after the second cardiopulmonary arrest, fiberoptic laryngoscopy revealed laryngomalacia. His respiratory condition stabilized after emergent tracheostomy. Laryngomalacia should be considered even in adult cases when signs of upper airway obstruction manifest after extubation.

Anatomic and physiopathologic changes affecting the airway of the elderly patient: implications for geriatric-focused airway management

There are many anatomical, physiopathological, and cognitive changes that occur in the elderly that affect different components of airway management: intubation, ventilation, oxygenation, and risk of aspiration. Anatomical changes occur in different areas of the airway from the oral cavity to the larynx. Common changes to the airway include tooth decay, oropharyngeal tumors, and significant decreases in neck range of motion. These changes may make intubation challenging by making it difficult to visualize the vocal cords and/or place the endotracheal tube. Also, some of these changes, including but not limited to, atrophy of the muscles around the lips and an edentulous mouth, affect bag mask ventilation due to a difficult face-mask seal. Physiopathologic changes may impact airway management as well. Common pulmonary issues in the elderly (eg, obstructive sleep apnea and COPD) increase the risk of an oxygen desaturation event, while gastrointestinal issues (eg, achalasia and gastroesophageal reflux disease) increase the risk of aspiration. Finally, cognitive changes (eg, dementia) not often seen as related to airway management may affect patient cooperation, especially if an awake intubation is required. Overall, degradation of the airway along with other physiopathologic and cognitive changes makes the elderly population more prone to complications related to airway management. When deciding which airway devices and techniques to use for intubation, the clinician should also consider the difficulty associated with ventilating the patient, the patient's risk of oxygen desaturation, and/or aspiration. For patients who may be difficult to bag mask ventilate or who have a risk of aspiration, a specialized supralaryngeal device may be preferable over bag mask for ventilation. Patients with tumors or decreased neck range of motion may require a device with more finesse and maneuverability, such as a flexible fiberoptic broncho-scope. Overall, geriatric-focused airway management is necessary to decrease complications in this patient population.

A case of acquired laryngomalacia in an infant, with endoscopy before and after establishing the diagnosis for the first time

A 12-week-old infant girl born at 27 weeks gestation, with multiple comorbidities, was referred to the paediatric otolaryngology team due to stridor and feeding difficulties. Initial airway endoscopy was performed, showing no abnormal findings. The infant underwent frequent hospitalisations for recurrent cyanotic spells. Despite initial laryngoscopy and bronchoscopy not showing abnormalities, a repeat endoscopy demonstrated laryngomalacia, significant enough to require a supraglottoplasty. This is the first report to confirm, with video evidence, that some cases of laryngomalacia are acquired rather than congenital, even in infancy.