Exercise-Induced Laryngeal Obstruction-An Overview

Epiglottic retraction is useful in diagnosis of exercise-induced laryngeal obstruction

Background: Exercise-induced laryngeal obstruction (EILO) is distinguished as upper airway obstruction accompanied by inspiratory dyspnoea and stridor during highly intensive exercises. Epiglottic retraction in the diagnosis of EILO has not been sufficiently explored. Aims/objectives: We highlight the importance of epiglottic retraction in patients with EILO by evaluation by several diagnostic methods for EILO. Consideration of epiglottic retraction may be important for accurate diagnosis of EILO. Results: Epiglottic retraction could be observed in three patients by laryngoscopy during heavy breathing and in two patients by continuous laryngoscopy during exercise. Stridor occurred by the forward prolapse of the arytenoids, but not by epiglottic retraction. In comparison with three athletes from other sports, lung volume was significantly greater in four swimmers although it was not different related to depending on the existence of epiglottic retraction. Conclusions and significance: Laryngoscopy during heavy breathing is suggested to be useful to detect the epiglottic retraction, which might be overlooked if only continuous laryngoscopy during exercise is used. Epiglottic retraction was not rare in Japanese swimmers' exercise-induced laryngeal obstruction in our cohort and it might be related to the greater lung volume.

Prevalence and characterisation of exercise-induced laryngeal obstruction in patients with exercise-induced dyspnoea

OBJECTIVE

The prevalence of exercise-induced laryngeal obstruction is largely unknown. This study aimed to evaluate the prevalence of this condition in a selected study population of patients with exercise-induced dyspnoea.

METHOD

A retrospective analysis was conducted of demographic data, co-morbidities, medication, symptoms, performance level of sporting activities, continuous laryngoscopy exercise test results and subsequent treatment.

RESULTS

Data from 184 patients were analysed. The overall prevalence of exercise-induced laryngeal obstruction in the study population was 40 per cent, and the highest prevalence was among females aged under 18 years (61 per cent). However, a high prevalence among males aged under 18 years (50 per cent) and among adults regardless of gender (34 per cent) was also found.

CONCLUSION

The prevalence of exercise-induced laryngeal obstruction is clinically relevant regardless of age and gender. Clinicians are encouraged to consider exercise-induced laryngeal obstruction as a possible diagnosis in patients suffering from exercise-induced respiratory symptoms. No single characteristic that can distinguish exercise-induced laryngeal obstruction from other similar conditions was identified.

Exercise-Induced Bronchoconstriction in Children

Exercise-induced bronchoconstriction (EIB) is a transient airflow obstruction, typically 5-15 min after physical activity. The pathophysiology of EIB is related to the thermal and osmotic changes of the bronchial mucosa, which cause the release of mediators and the development of bronchoconstriction in the airways. EIB in children often causes an important limitation to physical activities and sports. However, by taking appropriate precautions and through adequate pharmacological control of the condition, routine exercise is extremely safe in children. This review aims to raise awareness of EIB by proposing an update, based on the latest studies, on pathological mechanisms, diagnosis, and therapeutic approaches in children.

Exercise laryngoscopy in athletes and sportsmen: an easy way to assess exercise-induced laryngeal obstruction

BACKGROUND

Exercise-induced laryngeal obstruction (EILO) is an exercise-dependent dyspnoea, linked to a laryngeal closure during physical effort. It may concern from 5% to 7% of adolescents and young athletic adults. EILO is a quite recently described condition: standardized diagnostic criteria and consensual management are still to come. Formal diagnosis of EILO requires a continuous laryngoscopy during exercise (CLE). This test allows visualization of laryngeal abnormalities during an effort but is only accessible in specialized centres.

AIMS

We wanted to assess performance of a simplified CLE (sCLE) procedure for EILO diagnosis in everyday practice.

MATERIAL AND METHODS

The procedure consisted in a continuous flexible videolaryngoscopy during a cycloergometre cardio-pulmonary exercise test. Screening questionnaire and visual scoring of laryngeal abnormalities were performed. Patients clinically suspected of EILO were included from 2018 to 2020.

RESULTS

Seventeen consecutive subjects had an indication for sCLE. Fifteen patients underwent sCLE, and EILO-linked significative abnormalities were observed in 80% of them, thus confirming the diagnosis.

CONCLUSIONS

CLE can be done successfully in a simple way. Due to its simplicity, tolerance and contribution in EILO diagnosis, this simplified version of CLE may promote its widespread use in ENT and pulmonology practices, as an affordable confirmation test.

Characteristics and impact of exercise-induced laryngeal obstruction: an international perspective

Background

Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathlessness and wheeze yet is frequently misdiagnosed as asthma. Insight regarding the demographic characteristics, laryngeal abnormalities and impact of EILO is currently limited, with data only available from individual centre reports. The aim of this work was to provide a broader perspective from a collaboration between multiple international expert centres.

Methods

Five geographically distinct clinical paediatric and adult centres (3 Denmark, 1 UK, 1 USA) with an expertise in assessing unexplained exertional breathlessness completed database entry of key characteristic features for all cases referred with suspected EILO over a 5-year period. All included cases completed clinical asthma workup and continuous laryngoscopy during exercise (CLE) testing for EILO.

Results

Data were available for 1007 individuals (n=713 female (71%)) with a median (range) age of 24 (8–76) years, and of these 586 (58%) were diagnosed with EILO. In all centres, EILO was frequently misdiagnosed as asthma; on average there was a 2-year delay to diagnosis of EILO, and current asthma medication was discontinued in 20%. Collapse at the supraglottic level was seen in 60%, whereas vocal cord dysfunction (VCD) was only detected/visualised in 18%. Nearly half (45%) of individuals with EILO were active participants in recreational-level sports, suggesting that EILO is not simply confined to competitive/elite athletes.

Conclusion

Our findings indicate that key clinical characteristics and the impact of EILO/VCD are similar in globally distinct regions, facilitating improved awareness of this condition to enhance recognition and avoid erroneous asthma treatment.

Exercise-induced laryngeal obstruction is a prevalent cause of exertional breathlessness and wheeze. In this international multicentre collaboration, 1007 patients waited, on average, 2 years for diagnosis and 20% were mistreated as asthmatic.https://bit.ly/3auXpcp

Changes in pulmonary function and feasibility of portable continuous laryngoscopy during maximal uphill running

Objective

To evaluate changes in pulmonary function and feasibility of portable continuous laryngoscopy during maximal uphill running.

Methods

Healthy volunteers participated in an uphill race. Forced expiratory volume in 1 s (FEV₁) and forced vital capacity (FVC) were obtained before and 5 and 10 min after finishing the race. Capillary blood lactate concentration ([BLa^-]) and Borg score for perceived exertion were registered immediately after the race. One participant wore a portable video-laryngoscope during the race, and the video was assessed for technical performance.

Results

Twenty adult subjects participated with a mean (SD) age of 40.2 (9.7) years. Mean (SD) race duration and post-exercise [BLa^-] was 13.9 (2.3) min and 10.7 (2.1) mmol/L, respectively, and the median (range) Borg score for perceived exertion was 9 (5–10).

Mean percentage change (95% CI) 5 and 10 min post-exercise in FEV₁ were 6.9 (3.7 to 10.2) % and 5.9 (2.7 to 9.0) %, respectively, and in FVC 5.2 (2.3 to 8.1) % and 4.7 (1.6 to 7.9) %, respectively. The recorded video of the larynx was of good quality.

Conclusions

Maximal aerobic field exercise induced bronchodilatation in the majority of the healthy non-asthmatic participants. It is feasible to perform continuous video-laryngoscopy during heavy uphill exercise.

Life-threatening laryngeal injury in Elite Rugby Union: Prevention and management laryngeal trauma in rugby

Laryngeal trauma is a life-threatening injury in contact sports. Due to its potentially devastating consequences, the prevention, diagnosis, and management of neck trauma both pitch side and at the hospital are essential for athletes.

Prevalence of exercise-induced bronchoconstriction and laryngeal obstruction in adolescent athletes

OBJECTIVES

To study the prevalence of exercise-induced bronchoconstriction (EIB) and exercise-induced laryngeal obstruction (EILO) in adolescent athletes.

METHODS

All adolescents (n = 549) attending first year at a sports high school in 2016 and 2017, were invited to answer a questionnaire on respiratory symptoms. The 367 responding participants were divided into two groups based on whether they reported exercise-induced dyspnea (dyspnea group) or not (nondyspnea group). Randomly selected participants in each group were invited to undergo two standardized exercise tests, an EIB test and a continuous laryngoscopy exercise (CLE) test, to investigate EILO.

RESULTS

In total, 98 participants completed an EIB test, 75 of whom also completed a CLE test. Positive EIB tests: eight of 41 in the dyspnea group and 16 of 57 in the nondyspnea group. Positive CLE tests: 5 of 34 in the dyspnea group and three of 41 in the nondyspnea group. The estimated prevalence of EIB was 23.1% (95% confidence interval [CI]: 14.5-33.8) and of EILO 8.1% (95% CI: 2.5-18.5) in the whole study population. No differences in prevalence of EIB or EILO were found between the dyspnea and the nondyspnea groups.

CONCLUSION

EIB was highly prevalent in this cohort of adolescent athletes. EILO was less prevalent, but represents an important differential diagnosis to EIB. Self-reported exercise-induced dyspnea is a weak indicator for both EIB and EILO and standardized testing should be provided.

Surgical intervention for exercise-induced laryngeal obstruction: A UK perspective

OBJECTIVES

Exercise-induced laryngeal obstruction (EILO) is a prevalent cause of exertional breathlessness and wheeze in young individuals. Typically diagnosed using the continuous laryngoscopy during exercise (CLE) test, treatment is largely based on breathing retraining promoting improved laryngeal function. In some cases, these techniques fail to alleviate symptoms, and surgical intervention with supraglottoplasty can be valuable in the supraglottic form of EILO. Globally, there is currently limited experience utilizing a surgical approach to EILO, and data regarding the optimum surgical technique and published outcomes and complication rates are thus limited.

STUDY DESIGN

Retrospective observational case series.

METHODS

In this report, we describe our experience as the only UK center undertaking supraglottoplasty for EILO. We report the surgical outcome of 19 patients (n = 16 female), mean age, 29.6 ± 13.1 years, referred for surgery with moderate to severe supraglottic EILO. Follow-up clinic ± CLE was performed within 4 months (median = 6 weeks), and CLE scores were evaluated before and following surgery.

RESULTS

We found a beneficial effect of surgery on supraglottic CLE scores (median score reducing from 3/3 to 1/3 postoperatively [P < .05] overall) with 79% (n = 15) of patients reporting an improvement in their exercise capacity. One patient developed an apparent increased tendency for glottic-level EILO following surgery; however, no voice- or swallowing-related complications were encountered.

CONCLUSIONS

This study is the first to report the UK experience, surgical technique, and outcome for EILO surgery. The findings indicate that EILO surgery appears to be a safe and effective option for individuals with moderate to severe supraglottic-type EILO who have failed initial conservative treatment.

LEVEL OF EVIDENCE

5 Laryngoscope, 130:E667-E673, 2020.

Severe Exercise-Induced Laryngeal Obstruction Treated With Supraglottoplasty

Introduction: Exercise induced laryngeal obstruction (EILO) is relatively common in adolescents, with symptoms often confused with exercise induced asthma. EILO often starts with medial or inward rotation of supraglottic structures of the larynx, whereas glottic adduction appears as a secondary phenomenon in a majority. Therefore, surgical treatment (supraglottoplasty) is used in thoroughly selected and highly motivated patients with pronounced symptoms and severe supraglottic collapse.

Aim: To investigate efficacy and safety of laser supraglottoplasty as treatment for severe supraglottic EILO by retrospective chart reviews.

Methods: The EILO register at Haukeland University Hospital, Bergen, Norway was used to identify patients who had undergone laser supraglottoplasty for severe supraglottic EILO, verified by continuous laryngoscopy exercise (CLE) test, during 2013–2015. Laser incision in both aryepiglottic folds anterior to the cuneiform tubercles and removal of the mucosa around the top was performed in general anesthesia. Outcomes were questionnaire based self-reported symptoms, and laryngeal obstruction scored according to a defined scheme during a CLE-test performed before and after surgery.

Results: Forty-five of 65 eligible patients, mean age 15.9 years, were included. Post-operatively, 38/45 (84%) patients reported less symptoms, whereas CLE-test scores had improved in all, of whom 16/45 (36%) had no signs of obstruction. Most improvements were at the supraglottic level, but 21/45 (47%) also improved at the glottic level. Two of 65 patients had complications; self-limiting vocal fold paresis and scarring/shortening of plica ary-epiglottica.

Conclusion: Supraglottoplasty improves symptoms and decreases laryngeal obstruction in patients with severe supraglottic EILO, and appears safe in highly selected cases.

Feasibility of portable continuous laryngoscopy during exercise testing

Exercise-induced laryngeal obstruction (EILO) is a prevalent and yet still under-recognised cause of exertional breathlessness [1]. The transient closure of the larynx, which develops during EILO, results in dyspnoea, cough, inspiratory wheeze (i.e. stridor) and tightness in the throat on physical exertion. It is estimated that EILO is present in 6% of adolescents and as many as one in four athletes with unexplained respiratory symptoms [1, 2]. Despite improved recognition over the past 5 years [3, 4], it remains frequently misdiagnosed and mistreated as asthma [2, 5].

Exercise-induced laryngeal obstruction (EILO) is a prevalent problem causing exertional breathlessness and wheeze. This report demonstrates the feasibility and safety of a diagnostic approach to EILO, using a portable laryngoscope during exercise.http://ow.ly/eM6L30njDst

[Heart or lung? : Diagnostics and management of unclear exertional dyspnea]

Exertional dyspnea is a nonspecific symptom with a variety of underlying causes. It can be challenging to differentiate a beginning cardiac disease from a pulmonary disease or from deconditioning alone. In the presence of obesity, the overall assessment is even more difficult. Rare diseases, such as pulmonary hypertension with dyspnea on exertion as the cardinal symptom are usually diagnosed late in the course of disease. The starting point of a successful evaluation is a thorough patient history. The combination of symptoms, clinical signs and findings leads to a preferred differential diagnosis. Readily available basic findings, such as physical examination, electrocardiogram (ECG), spirometry and laboratory tests help with the diagnosis. For unexplained causes, extended diagnostics such as echocardiography, blood gas analysis and finally special examinations are available. Cardiopulmonary exercise testing (CPET) and exercise echocardiography as well as right heart catheterization at rest and during exercise in the hands of experienced physicians allow an exact differentiation.