Bifid epiglottis associated with Joubert's syndrome

Bardet-Biedl Syndrome Presenting With Bifid Epiglottis: A Case Report and Review of Literature

Bifid epiglottis is a rare congenital laryngeal anomaly that is most commonly a syndromic rather than an isolated entity. It has been associated with specific syndromes, such as Pallister-Hall syndrome, Bardet-Biedl syndrome, and other related syndromes. Bardet-Biedl syndrome is a rare autosomal-recessive disorder characterized by hand and/or feet polydactyly, obesity, short stature, mental retardation, renal anomalies, and genital anomaly. Here we report a case involving a 25-year-old Saudi male patient who presented with hoarseness of voice since birth with no diurnal or diet association or other associated symptoms. On examination, he was noted to have craniofacial dysmorphism and polydactyly of the right hand and left foot. Fiberoptic nasopharyngolaryngoscopy (NPLS) revealed a laryngeal pedunculated rounded glottic mass and subglottic bulging with expiration and involuting with inspiration along with an abnormal-looking epiglottis having a separate cartilaginous framework with space in-between and bilateral mobile vocal cords. Computed tomography (CT) showed the vocal cord mass and a bifid epiglottis. Other investigations and labs were within normal range. The patient underwent vocal cord mass excision and soft tissue histopathology revealed a benign growth. On follow-up, the patient showed clinical improvement. In conclusion, this is a rare case of bifid epiglottis associated with Bardet-Biedl syndrome, which serves to highlight the significance of such anomalies in any syndromic patient presenting with airway symptoms. Our aim is to add more cases to the literature and to consider it as a differential diagnosis.

Epiglottic aplasia in an infant with Joubert syndrome

Congenital aplasia of the epiglottis is a rare condition with variable presentation ranging from respiratory distress requiring surgical airway to an asymptomatic finding. Epiglottic aplasia is presumed to be caused by arrest of development of laryngeal structures and is most commonly associated with syndromic conditions, though isolated episodes of aplasia of the epiglottis do exist. In this report, we present a term infant with multiple congenital anomalies who was noted to have a hoarse cry prompting laryngoscopy. This showed complete absence of the epiglottis. Subsequent genetic testing showed mutations in the CPLANE1 gene that is associated with Joubert syndrome. Our patient was able to be discharged home on a thickened formula diet and is eating and gaining weight appropriately. Here, we present a review of the currently available literature of other cases of congenital epiglottic aplasia or hypoplasia discussing the presentation, management and outcomes in these cases.

The morphometric development of the fetal larynx during the fetal period

OBJECTIVE

The aim of the present study was to investigate morphometric growth patterns of the cartilaginous components and vocal cords in human fetal larynx.

METHODS

This study was performed in the Anatomy Department of Meram Medicine Faculty in 2007. The fetuses were obtained from the Gynaecology Department of the Meram Medicine Faculty of Selcuk University, and Dr. Faruk Sükan Maternity Hospital (Konya, Turkey). Forty spontaneously aborted fetuses (25 males and 15 females) without detectable malformations were evaluated. The dimensions of the larynx and its cartilaginous components were measured and the relationship between the obtained data was statistically assessed with Student's t-test.

RESULTS

Correlations were found between the cartilaginous components, size of the larynx, and gestational age. No gender differences were identified. The anatomical variations in the epiglottis cartilage dimensions and types were found in 15% of cases. The foramen thyroideum was observed in 12.5% of cases.

CONCLUSION

The data of this study may contribute to the knowledge of the fetal larynx regarding laryngomalacia.

Significance of bifid epiglottis

Bifid epiglottis is a rare anomaly, which is heterogeneous and is often associated with other anomalies, particularly polydactyly. It has been reported in 40% of patients with Pallister-Hall syndrome and rarely in other syndromes. We report two brothers with bifid epiglottis who also have features suggestive of Bardet-Biedl syndrome. We also review the features seen in 22 patients reported in the literature with bifid epiglottis. No patient had bifid epiglottis as an isolated anomaly. Other malformations include clefts, micropenis, renal abnormalities, anal malformations, hypospadias, hypothalamic hamartomas, hypopituitarism, heart defects, and Hirschprung disease. Bifid epiglottis may be an under-recognized feature of Bardet-Biedl syndrome and should be considered in these patients, particularly if there are airway symptoms. Many of the anomalies associated with bifid epiglottis have potentially serious consequences and thus, a thorough evaluation of the patient with bifid epiglottis is warranted.

Anesthetic management in Joubert syndrome

We review the anesthetic implications of Joubert syndrome and report that spinal anesthesia under intravenous propofol sedation proved satisfactory for repair of an inguinal hernia in a spontaneously ventilating infant with this syndrome. We caution that anatomical peculiarities may complicate performance of a caudal epidural block and suggest consideration of the use of caffeine to ameliorate the apneic episodes seen in early infancy in this syndrome.

Nystagmus

This article reviews the recent literature on nystagmus and various aspects of the pathophysiology of congenital idiopathic nystagmus and nystagmus treatment. One paper shows a new classification of latent/manifest latent nystagmus based on eye movement recordings. Nystagmus associated with complex syndromes and with onset in childhood represents the subject of several important recent articles, as does acquired nystagmus. Nystagmus as a manifestation of the toxicity of pharmacological agents is becoming increasingly recognized. Important contributions have been made to the genetics of various forms of nystagmus that represent an essential feature of retinal diseases, such as congenital stationary night blindness, albinism, blue cone monochromatism, and achromatopsia.