Epiglottic retroversion as a cause of upper airway obstruction: A case report

RATIONALE

Epiglottic retroversion is the abnormal movement of the epiglottis to the rima glottis, resulting in blockage of inspiratory airflow. Acute upper airway obstruction caused by epiglottic retroversion can lead to sudden respiratory failure. Epiglottic retroversion has occasionally been reported in horses and dogs; however it is extremely rare in humans. Herein, we report a case of epiglottic retroversion causing recurrent upper airway obstruction in human.

PATIENT CONCERNS

We present the case of a 74-year-old man who was diagnosed with epiglottic retroversion without evidence of epiglottis. The patient presented with recurrent episodes of abnormal breathing sounds and dyspnea. Inspiratory stridor was evident whenever the patient experienced dyspnea.

DIAGNOSIS

Epiglottic retroversion was diagnosed as the cause of upper airway obstruction using fiber-optic bronchoscopy.

INTERVENTIONS

The patient underwent tracheostomy to prevent acute respiratory failure because the recurrent episodes of stridor and dyspnea did not improve.

OUTCOMES

The episodic dyspnea and oxygen desaturation did not relapse after tracheostomy and he could be discharged home.

LESSONS

This case highlights the importance of considering epiglottic retroversion as a cause of acute upper airway obstruction.

Reliability of fluoroscopic examination of nasopharyngeal dorsoventral dimension change in pugs and French bulldogs

OBJECTIVE

To compare intra- and interobserver agreements in two-dimensional measurements of changes in nasopharyngeal dimensions during breathing in pugs and French bulldogs.

STUDY DESIGN

Experimental randomized study.

ANIMALS

A total of 20 French bulldogs and 16 pugs.

METHODS

Four observers with different levels of experience measured the dorsoventral dimensions of the nasopharynx during inspiration and expiration on fluoroscopy videos. Measurements were performed at the maximal narrowing of the nasopharynx for the functional method and at the level of the tip of the epiglottis for the anatomically adjusted method. The intra- and interobserver agreements of the measurements, ratio of the dynamic nasopharyngeal change (ΔL), and grade of nasopharyngeal (NP) collapse (no, partial or complete) were evaluated.

RESULTS

The functional method resulted in intraobserver correlation coefficients of 0.532 (p < .01) and 0.751 (p < .01) and interobserver correlation coefficients of 0.378 (p < .01) and 0.621 (p < .01) for NP collapse grade and ΔL, respectively. The anatomically adjusted method, 0.491 (p < .01) and 0.576 (p < .01) and 0.495 (p < .01) and 0.729 (p < .01) for NP collapse grade and ΔL, respectively, were being used. One observer (radiologist) achieved intraobserver correlation coefficients >0.9 for both methods.

CONCLUSION

Fair interobserver agreement was found for NP collapse grade (functional method), moderate intra- and interobserver agreements were found for NP collapse grade and ΔL (both methods) while intraobserver agreement for ΔL was good (functional method).

CLINICAL SIGNIFICANCE

Both methods seem repeatable and reproducible but only for experienced radiologists. The use of ΔL may offer higher repeatability and reproducibility than grade of NP collapse regardless of the method used.

Treatment of a floppy epiglottis with upper airway stimulation therapy

PURPOSE

To evaluate the efficacy of upper airway stimulation therapy in patients with a floppy epiglottis who have experienced continuous positive airway pressure failure or intolerance.

METHODS

A retrospective single-center cohort study was conducted. Patients who received an Inspire Upper Airway Stimulation system and had a 1-year follow-up were included. Baseline and one-year in-laboratory polysomnography examinations were performed. Patient characteristics, Epworth Sleepiness Scale scores and upper airway stimulation device settings were collected.

RESULTS

A total of 75 patients were included, of whom 10 had a floppy epiglottis. Patients with a floppy epiglottis had a significant therapeutic response to upper airway stimulation therapy, similar to patients without a floppy epiglottis. According to the Sher's success criteria, 90% of patients with a floppy epiglottis and 68% of patients without a floppy epiglottis were responders to therapy (p = 0.149). In the floppy epiglottis group, the apnea-hypopnea index decreased from 35.1 ± 5.5 events/hour to 11.2 ± 11.3 events/hour (95% CI (15.0, 32.9), p < 0.001), similarly in the non-floppy epiglottis group, the decline was from 36.4 ± 8.3 events/hour to 14.4 ± 9.5 events/hour (95% CI (18.6, 25.2), p < 0.001, between groups p = 0.659). Comparable reductions were observed for the other respiratory parameters.

CONCLUSION

Treatment of patients with obstructive sleep apnea and a floppy epiglottis can be challenging. Continuous positive airway pressure may aggravate the epiglottis collapse. Upper airway stimulation therapy can be considered an effective alternative treatment option for patients with a floppy epiglottis who have encountered either continuous positive airway pressure failure or intolerance.

Effects of Head and Neck Alignment and Pharyngeal Anatomy on Epiglottic Inversion During Swallowing in Dysphagic Patients

The effects of head and neck alignment and pharyngeal anatomy on epiglottic inversion remain unclear. This study investigated the factors involved in epiglottic inversion, including head and neck alignment and pharyngeal anatomy, in patients with dysphagia. Patients with a chief complaint of dysphagia and who underwent videofluoroscopic swallowing study at our hospital from January to July 2022 were enrolled. They were divided into three groups based on the degree of epiglottic inversion as the complete-inversion (CI), partial-inversion (PI), and non-inversion group (NI) groups. Data were compared among the three groups; a total of 113 patients were analyzed. The median age was 72.0 (IQR: 62.0-76.0) years; 41 (36.3%) and 72 (63.7%) were women and men, respectively. There were in 45 (39.8%) patients in the CI, 39 (34.5%) in the PI, and 29 (25.7%) in the NI groups, respectively. Single-variable analysis revealed significant relation to epiglottic inversion of Food Intake LEVEL Scale score, penetration-aspiration score with 3-mL thin liquid bolus, epiglottic vallecula and pyriform sinus residue, hyoid position and displacement during swallowing, pharyngeal inlet angle (PIA), epiglottis to posterior pharyngeal wall distance, and body mass index. Logistic regression analysis with complete epiglottic inversion as the dependent variable revealed the X coordinate at maximum hyoid elevation position during swallowing and PIA as significant explanatory variables. These results suggest that epiglottic inversion is constrained in patients with dysphagia who have poor head and neck alignment or posture and a narrow pharyngeal cavity just before swallowing.

Defining Normal Sequential Swallowing Biomechanics

Little is known about the physiology of a common fluid ingestion pattern-sequential swallowing. This study investigated sequential swallowing biomechanics in healthy adults. Archival normative videofluoroscopic swallow studies were analyzed for hyolaryngeal complex (HLC) patterning and biomechanical measures from the first 2 swallows of a 90-mL thin liquid sequential swallow task. The effects of age, sex, HLC type, and swallow order were explored. Eighty-eight participants were included in the primary analyses as they performed sequential swallows. HLC Type I (airway opens, epiglottis approaches baseline) and Type II (airway remains closed, epiglottis remains inverted) most commonly occurred (47% each), followed by Type III (mixed, 6%). Age was significantly associated with Type II and longer hypopharyngeal transit, total pharyngeal transit (TPT), swallow reaction time (SRT), and duration to maximum hyoid elevation. Males demonstrated significantly greater maximum hyoid displacement (Hmax) and longer duration of maximum hyoid displacement. Significantly larger maximum hyoid-to-larynx approximation was linked to the first swallow, while the subsequent swallow had significantly longer oropharyngeal transit, TPT, and SRT. Secondary analyses included an additional 91 participants who performed a series of discrete swallows for the same swallow task. Type II had significantly greater Hmax than Type I and series of discrete swallows. Sequential swallowing biomechanics differ from discrete swallows, and normal variance exists among healthy adults. In vulnerable populations, sequential swallowing may challenge swallow coordination and airway protection. Normative data allow comparison to dysphagic populations. Systematic efforts are needed to further standardize a definition for sequential swallowing.

Three-dimensional architecture of the subepithelial corpuscular nerve ending in the rat epiglottis reconstructed by array tomography with scanning electron microscopy

In the rat laryngeal mucosa, subepithelial corpuscular nerve endings, called laminar nerve endings, are distributed in the epiglottis and arytenoid region and are activated by the pressure changes of the laryngeal cavity. They are also suggested to play a role in efferent regulation because of secretory vesicles in the axoplasm. In the present study, the laminar nerve endings in the rat laryngeal mucosa were analyzed by 3D reconstruction from serial ultrathin sections in addition to immunohistochemistry for synapsin 1. In the light microscopy, synapsin 1-immunoreactive flattened or bulbous terminal parts of the laminar endings were also immunoreactive with VGLUT1, and were surrounded by S100- or S100B-immunoreactive Schwann cells and vimentin-immunoreactive fibroblasts. In the electron microscopy, 3D reconstruction views showed that laminar endings were composed of flattened terminal parts sized 2-5 μm in longitudinal length, overlapping in three to five multiple layers. The terminal parts of the endings were incompletely wrapped by flat cytoplasmic processes of the Schwann cells. In addition, the fibroblast network surrounded the complex of nerve endings and the Schwann cells. Several terminal parts entered through the basement membrane into the epithelial layer and attached to the basal epithelial cells, suggesting that interaction between epithelial cells and laminar nerve endings plays an important role in sensing the pressure changes in the laryngeal cavity. Secretory vesicles were unevenly distributed throughout the terminal part of the laminar nerve endings. The secretory vesicles were frequently observed in the peripheral limb of the terminal parts. It suggests that the laminar nerve endings in the larynx may release glutamate to maintain continuous discharge during the stretching of the laryngeal mucosa.

CBCT Analysis of Oropharynx Airway Volume

OBJECTIVE

The study was performed to analyze the oropharynx airway and examine the influence of age and gender on the oropharynx volume configuration using cone beam computed tomography.

MATERIALS AND METHODS

This study examined the cone beam computed tomographic images of 51 patients 25 male and 26 females, group matched for age and gender. The oropharynx airway volume and area between the posterior nasal spine and top of the epiglottis were measured and compared.

RESULTS

The statistical measurements of 51 cone beam computed tomography images showed a nonsignificant difference found between male and female regarding the age (the mean age for female 40.15 y. and for male32.72 y). Male subjects had greater oropharynx volume, a high significant difference ( P =0.005) in oropharynx volume between the 3 age groups. A significant difference was found between the smallest age group with the larger age groups.

CONCLUSION

The study data revealed that the changes in measurements of oropharynx airway are age-dependent in addition to gender effect.

Displaced transverse laryngeal fracture from attempted hanging

Laryngeal fractures are life-threatening injuries, frequently associated with long-term morbidity. We present a case of a man sustaining a displaced laryngeal fracture and rupture of supraglottic structures following attempted suicide by hanging from a bridge. His injuries included a tear of the thyrohyoid membrane, avulsed epiglottis and complete autopharyngotomy. All laryngeal functions were significantly impaired. Early tracheostomy, careful surgical repair, extensive multidisciplinary team (MDT) input and intensive rehabilitation all contributed towards a successful recovery. By 7 months following the initial injury, the patient had achieved excellent breathing and voicing, and a safe and competent swallow despite the extent of his initial injuries. This case demonstrates the importance of early airway management in laryngeal trauma and the role of surgical management in conjunction with swallow rehabilitation. Fundamentally, an MDT approach is essential for the holistic management of patients with laryngeal trauma.

The size, number, and distribution of nerve endings around and within the human epiglottis, focusing on tracheal intubation maneuvers

The aim of this study was to examine the distribution of nerve endings in the mucosa, submucosa, and cartilage of the epiglottis and the vallecula area and to quantify them. The findings could inform the choice of laryngoscope blades for intubation procedures. Fourteen neck slices from seven unembalmed, cryopreserved human cadavers were analyzed. The slices were stained, and cross and longitudinal sections were obtained from each. The nerve endings and cartilage were identified. The primary metrics recorded were the number, area, and circumference of nerve endings located in the mucosa and submucosa of the pharyngeal and laryngeal sides of the epiglottis, epiglottis cartilage, and epiglottic vallecula zone. The length and thickness of the epiglottis and cartilage were also measured. The elastic cartilage of the epiglottis was primarily continuous; however, it contained several fragments. It was covered with dense collagen fibers and surrounded by adipose cells from the pharyngeal and laryngeal submucosa. Nerve endings were found within the submucosa of pharyngeal and laryngeal epiglottis and epiglottic vallecula. There were significantly more nerve endings on the posterior surface of the epiglottis than on the anterior surface. The epiglottic cartilage was twice the length of the epiglottis. The study demonstrated that the distribution of nerve endings in the epiglottis differed significantly between the posterior and anterior sides; there were considerably more in the former. The findings have implications for tracheal intubation and laryngoscope blade selection and design.

The relationship between bi-spectral index and VOTE score in evaluation of drug-induced sleep endoscopy: A systematic meta-analysis

OBJECTIVE

The aim of this study was to investigate both the presence and severity of collapse in anatomical regions defined by the VOTE score (velum, orofarinx, tongue, and epiglottis), during drug induced sleep endoscopy (DISE) in patients diagnosed with obstructive sleep apnea, based on the bi-spectral index (BIS) sedation level.

METHODS

In order to conduct a meta-analysis of articles examining the relationship between the VOTE score and BIS sedation level in determining the presence and severity of upper airway collapse during DISE, a literature review was performed.

RESULTS

As a result of the search made in the specified databases, a total of 1864 articles were reached. Five articles included in this review that had sufficient statistical data to be included in the meta-analysis were found. A statistically significant correlation was found between the BIS sedation level and the areas of obstruction in the VOTE score. The strongest association is at the epiglottis level, followed by the velum, oropharynx, and tongue, respectively (CC: 0.639, CC: 0.53, CC: 0.49, and CC: 0.346, P < .001). In the subgroup analysis of publications with BIS sedation levels in the range of 60 to 65, the distribution in the epiglottis region was heterogeneous, and it was found to be statistically significant according to the random effect model (P < .001). The distribution in the tongue was homogeneous, and it was found to be statistically significant according to the fixed effect model (P < .001). When the publications in which the BIS sedation level is in the range of 65 to 75 are examined according to the areas of obstruction; the distribution in 4 anatomical regions was homogeneous and statistically significant according to the fixed effect model (P < .001).

CONCLUSION

It was found that BIS sedation levels during DISE application in obstructive sleep apnea patients were associated with obstruction of the anatomical regions of the upper airway. The strongest association was found at the epiglottis level, followed by the velum, oropharynx, and tongue, respectively. It is helpful to monitor the sedation level with BIS in order to better define the collapsed areas during DISE application. However, more studies are needed to better understand the relationship between BIS sedation values and sleep stages.

Tongue retraction using a McIvor blade improves airway condition during fiberoptic intubation: a randomized controlled trial

Airway clearance is crucial for successful fiberoptic intubation. We hypothesized that tongue retraction using a McIvor blade could facilitate fiberoptic intubation. This randomized clinical trial aimed to compare intubation time and airway condition between the jaw thrust maneuver and tongue retraction with the McIvor blade during fiberoptic intubation. Ninety-four adult patients scheduled for elective surgery were randomly assigned to one of two groups. During fiberoptic intubation, airway clearance was secured by applying the jaw-thrust maneuver (J group) or by tongue retraction using the McIvor blade (M group). We assessed the total intubation time, number of attempts for tube advancement, and airway clearance at the soft palate and epiglottis levels. The total intubation time was significantly shorter in the M group than in the J group (p = 0.035). The number of attempts to advance the tube was significantly lower in the M group (p = 0.033). Airway clearance at the soft palate level was significantly better in the M group than in the J group (p = 0.027). Retracting the tongue with the McIvor blade demonstrated a better condition for fiberoptic intubation and shortened total intubation time compared with the jaw-thrust maneuver.Clinicalregistiration: CRIS; http://cris.nih.go.kr (KCT0002392) registered 28/07/2017.

Direct versus indirect epiglottis elevation in cervical spine movement during videolaryngoscopic intubation under manual in-line stabilization: a randomized controlled trial

BACKGROUND

During videolaryngoscopic intubation, direct epiglottis elevation provides a higher percentage of glottic opening score than indirect epiglottis elevation. In this randomized controlled trial, we compared cervical spine movement during videolaryngoscopic intubation under manual in-line stabilization between the two glottis exposure methods.

METHODS

Videolaryngoscopic intubation under manual in-line stabilization was performed using C-MAC® D-blade: direct (n = 51) and indirect (n = 51) epiglottis elevation groups. The percentage of glottic opening score was set equally at 50% during videolaryngoscopic intubation in both groups. The primary outcome measure was cervical spine movement during videolaryngoscopic intubation at the occiput-C1, C1-C2, and C2-C5. The secondary outcome measures included intubation performance (intubation success rate and intubation time).

RESULTS

Cervical spine movement during videolaryngoscopic intubation was significantly smaller at the occiput-C1 in the direct epiglottis elevation group than in the indirect epiglottis elevation group (mean [standard deviation] 3.9 [4.0] vs. 5.8 [3.4] °, P = 0.011), whereas it was not significantly different at the C1-C2 and C2-C5 between the two groups. All intubations were successful on the first attempt, achieving a percentage of glottic opening score of 50% in both groups. Intubation time was longer in the direct epiglottis elevation group (median [interquartile range] 29.0 [24.0-35.0] vs. 22.0 [18.0-27.0] s, P < 0.001).

CONCLUSIONS

When performing videolaryngoscopic intubation under manual in-line stabilization, direct epiglottis elevation can be more beneficial than indirect epiglottis elevation in reducing cervical spine movement during videolaryngoscopic intubation at the occiput-C1.

TRIAL REGISTRATION

Clinical Research Information Service (number: KCT0006239, date: 10/06/2021).

A case of epiglottic entrapment in a cat

OBJECTIVE

The objective of this study was to describe a case of epiglottic entrapment in a cat.

CASE SUMMARY

A 5-month-old male neutered Russian Blue cat was evaluated for progressive stertorous upper airway sounds, acute onset vestibulopathy and abnormal laryngeal anatomy. Endotracheal intubation was only able to be achieved using videoscopic guidance and identified concern for severe nasopharyngeal stenosis. A computerized tomography scan revealed otitis interna, narrowed nasopharynx and no definitive cause for the stertorous breathing. The cat recovered very slowly from anaesthesia due to concern for airway obstruction following extubation. It was discharged the following day and then passed away at home 2 weeks later. Necropsy revealed that the epiglottis was obscured by 2 cm of redundant mucosal tissue extending from the base of the tongue to the larynx resulting in epiglottic entrapment. Also noted was chronic, severe otitis interna and externa. Upper airway obstruction is suspected to be the cause of sudden death.

NEW OR UNIQUE INFORMATION

To the authors' knowledge, this is the first report of these oropharyngeal anatomic abnormalities in a cat.

Oral appliance therapy for obstructive sleep apnea in multiple system atrophy with floppy epiglottis: a case series of three patients

PURPOSE

A recent study demonstrated that continuous positive airway pressure (CPAP) may exacerbate obstructive sleep apnea (OSA) in patients with multiple system atrophy (MSA) and a floppy epiglottis (FE) as the CPAP promotes downward displacement of the epiglottis into the laryngeal inlet. In this case series, we examined the effectiveness of an oral appliance (OA) for treating OSA in three patients with MSA and an FE.

METHODS

Patients with MSA were demonstrated to have an FE on fiberoptic laryngoscopy under sedation using intravenous propofol. The therapeutic intervention was fitting an OA. Polysomnography (PSG) was performed subsequently with the OA in place.

RESULTS

In three patients with MSA, some parameters used to assess the severity of OSA improved with an OA. Both apnea-hypopnea index (AHI) and arousal index (ArI) decreased while wearing the OA in two cases while in the third case, apnea index (AI) and cumulative time at peripheral oxygen saturation (SpO₂) below 90% (CT90) decreased, but AHI and ArI increased. The only side effects were transient TMJ discomfort, masseter muscle pain, and tooth discomfort.

CONCLUSION

OA therapy using a two-piece type mandibular advancement device (MAD) may be a useful treatment intervention for patients with OSA who have MSA and FE.

Ultrasound measurements for evaluation of changes in upper airway during anaesthesia induction and prediction difficult laryngoscopy: a prospective observational study

Upper airway collapsibility after anaesthesia induction may be associated with unpredictable difficult airway. However, most works on airway anatomy are tended to morphological description before anaesthesia. This study aimed to evaluate the changes of upper airway after anaesthesia induction and using pre-anesthetic ultrasound measurements to predict Difficult Laryngoscopy (DL). We included 104 eligible subjects with complete data, who were performed tracheal intubations under general anaesthesia in the study. The upper airway changes before and after anaesthesia induction were determined by seven neck ultrasound measurements, included as follow: (1) Distance from skin to under surface of Tongue (DT), (2) Thickness of the thickest part of Tongue body (TT), (3) Hyoid Mental Distance (HMD), (4) Depth of Hyoid (DH), (5) Width of Hyoid (WH), (6) Distance from Skin to Epiglottis (DSE), (7) Depth of the anterior combination of the Vocal Cords (DVC). DL was evaluated with Cormack-Lehane (CL). Data regarding HMD [from 45.3 (42.4-48.5) to 41.1 (38.5-44.9) mm], DH [from 8.7 (6.6-10.9) to 7.0 (5.3-9.1) mm], DSE [from 20.1 (16.6-22.5) to 19.5 (16.5-21.6) mm] and the DVC [from 7.1 (5.7-8.3) to 6.8 (5.7-7.9) mm] were decreased (P < 0.05), while the DT [from 15.9 (13.1-18.4) to 17.4 (14.5-19.8) mm] was increased (P > 0.05) after anaesthesia induction. Additionally, when cut-off value of DSE was 21.25 mm before anaesthesia, it may be better predicted to DL [sensitivity 80.0% (95% CI: 60.7-91.6%) and specificity 83.8% (95% CI: 73.0-91.0%)]. The upper airway after induction showed the propensity of collapsibility by ultrasound measurements. Compared with other indicators, the DSE assessed by ultrasound might be considered to a valuable predictor of DL.Trial registration: The study was registered in ClinicalTrials.gov on 23th Jan 2019, ChiCTR1900021123.

Patients with Epiglottic Collapse Are Less Adherent to Autotitrating Positive Airway Pressure Therapy for Obstructive Sleep Apnea

Rationale: The anatomic orientation of the epiglottis is such that it points in the opposite direction to inspiratory flow, thereby potentially making positive airway pressure (PAP) treatment challenging in patients with epiglottic collapse. However, no previous studies have analyzed PAP adherence in these patients. Objectives: This study aimed to analyze adherence to autotitrating PAP (APAP) treatment in patients with epiglottic collapse. Methods: We performed an age- and sex-matched case-control study. On the basis of their overnight level-I polysomnogram, patients were prescribed APAP in a tertiary hospital between July 2018 and March 2019. The site of airway collapse was diagnosed with drug-induced sleep endoscopy. Demographic factors, sleep questionnaire, polysomnography, and APAP usage statistics were analyzed. Results: Eighteen patients with epiglottic collapse (epi-group) and 36 without epiglottic collapse (control group) were analyzed. We found that 22.8% of patients in the epi-group terminated APAP within 2 weeks, whereas only 2.8% of patients in the control group terminated APAP within 2 weeks (P = 0.048). The percentage of days with usage over 4 hours was significantly lower in the epi-group (64.6% vs. 75.6%; P = 0.008). In addition, the adherence failure rate was 66.7% in the epi-group and 33.3% in the control group (P = 0.039). Patients with epiglottic collapse were also found to have lower body mass index, which is an unfavorable predictor of APAP adherence. Conclusions: This study suggests that patients with epiglottic collapse have a higher APAP adherence failure rate than patients without epiglottic collapse. Thus, patients with epiglottic collapse should be followed closely during treatment, and alternative therapies should probably be considered for these patients.

Spindle cell lipoma of the epiglottis: a potential airway emergency

Nil.

Pulmonary Sarcomatoid Carcinoma With Epiglottis and Ileum Metastasis Detected by 18F-FDG PET/CT

ABSTRACT

Pulmonary sarcomatoid carcinoma is a rare subtype of non-small cell lung cancer with poor prognosis. It often metastasizes to lymph nodes, bone, adrenal gland, liver, and brain. Herein, we present a case of a pulmonary sarcomatoid carcinoma patient with epiglottis and ileum metastasis detected by 18F-FDG PET/CT. Lymphoma or multiple primary cancers with or without regional node metastasis were suspected. Ultimately, histopathology after biopsy revealed pulmonary sarcomatoid carcinoma with epiglottic and ileum metastases. Our case highlights the unique advantages of 18F-FDG PET/CT in searching for the unsuspected metastasis.

Upper Airway Classification in Sleep Endoscopy Examinations using Convolutional Recurrent Neural Networks. Annu Int Conf IEEE Eng Med Biol Soc 2021;2021:3957-3960. [PMID: 34892097 DOI: 10.1109/embc46164.2021.9630098]

Assessing the upper airway (UA) of obstructive sleep apnea patients using drug-induced sleep endoscopy (DISE) before potential surgery is standard practice in clinics to determine the location of UA collapse. According to the VOTE classification system, UA collapse can occur at the velum (V), oropharynx (O), tongue (T), and/or epiglottis (E). Analyzing DISE videos is not trivial due to anatomical variation, simultaneous UA collapse in several locations, and video distortion caused by mucus or saliva. The first step towards automated analysis of DISE videos is to determine which UA region the endoscope is in at any time throughout the video: V (velum) or OTE (oropharynx, tongue, or epiglottis). An additional class denoted X is introduced for times when the video is distorted to an extent where it is impossible to determine the region. This paper is a proof of concept for classifying UA regions using 24 annotated DISE videos. We propose a convolutional recurrent neural network using a ResNet18 architecture combined with a two-layer bidirectional long short-term memory network. The classifications were performed on a sequence of 5 seconds of video at a time. The network achieved an overall accuracy of 82% and F1-score of 79% for the three-class problem, showing potential for recognition of regions across patients despite anatomical variation. Results indicate that large-scale training on videos can be used to further predict the location(s), type(s), and degree(s) of UA collapse, showing potential for derivation of automatic diagnoses from DISE videos eventually.

[Life-threatening oedema triggered by inhalation of nitrous oxide]

In this case report we describe a life-threatening oedema in a 20-year-old woman triggered by inhalation of nitrous oxide. On admission, flexible rhinolaryngoscopy revealed a rapidly progressing oedema of the epiglottis and arytenoid region. The patient was immediately intubated and transferred to the intensive care unit. Due to progression of the oedema a surgical tracheostomy was performed. On day six the canula was removed, and the patient could be discharged in good condition.

Multiple Epidermal Inclusion Cysts of Epiglottis

Epiglottic cysts are benign laryngeal lesions. Though congenital cysts are often life-threatening, they are usually painless and symptomless in adults, or present with slight, though perceptible, interference with either swallowing or speaking or respiration. Early recognition and diagnosis by routine mirror laryngoscopy is advocated. Prompt removal or draining is the treatment. This is a case report of 42-year-old woman with complaints of feeling of something in throat, sleep apnoea and hoarseness, who on routine mirror laryngoscopy was found to have two large cysts arising from the free border of the epiglottis. The final histopathology reported the cysts as epidermal inclusion cysts.

Postnatal Development of the Mouse Larynx: Negative Allometry, Age-Dependent Shape Changes, Morphological Integration, and a Size-Dependent Spectral Feature

Purpose The larynx plays a role in swallowing, respiration, and voice production. All three functions change during ontogeny. We investigated ontogenetic shape changes using a mouse model to inform our understanding of how laryngeal form and function are integrated. We understand the characterization of developmental changes to larynx anatomy as a critical step toward using rodent models to study human vocal communication disorders. Method Contrast-enhanced micro-computed tomography image stacks were used to generate three-dimensional reconstructions of the CD-1 mouse (Mus musculus) laryngeal cartilaginous framework. Then, we quantified size and shape in four age groups: pups, weanlings, young, and old adults using a combination of landmark and linear morphometrics. We analyzed postnatal patterns of growth and shape in the laryngeal skeleton, as well as morphological integration among four laryngeal cartilages using geometric morphometric methods. Acoustic analysis of vocal patterns was employed to investigate morphological and functional integration. Results Four cartilages scaled with negative allometry on body mass. Additionally, thyroid, arytenoid, and epiglottic cartilages, but not the cricoid cartilage, showed shape change associated with developmental age. A test for modularity between the four cartilages suggests greater independence of thyroid cartilage shape, hinting at the importance of embryological origin during postnatal development. Finally, mean fundamental frequency, but not fundamental frequency range, varied predictably with size. Conclusion In a mouse model, the four main laryngeal cartilages do not develop uniformly throughout the first 12 months of life. High-dimensional shape analysis effectively quantified variation in shape across development and in relation to size, as well as clarifying patterns of covariation in shape among cartilages and possibly the ventral pouch. Supplemental Material https://doi.org/10.23641/asha.12735917.

The anesthesia airway evaluation: Correlation with sleep endoscopy findings

PURPOSE

Drug-induced sleep endoscopy (DISE) is a cost-effective, safe, and reliable tool to evaluate obstructive sleep apnea (OSA) patients by revealing upper airway sites, patterns, and severity of obstruction. DISE provides valuable data because reliable evaluation of the OSA airway while awake has remained elusive. Few studies (with mixed results) have analyzed the correlation between pre-operation, awake airway assessments routinely performed by anesthesia and DISE results.

METHODS

Preoperative anesthesia evaluation records and subsequent DISE reports were obtained for 99 adult patients undergoing DISE between 2016 and 2018. All patients carried the diagnosis of OSA, based on polysomnography. Anesthesia-collected variables were compared with DISE findings in an effort to determine if commonly-utilized physical exam findings correlated to patterns of upper airway collapse observed on sleep endoscopy.

RESULTS

Most anesthesia preoperative evaluation variables were not found to be predictive of any identifiable patterns of collapse on DISE, including Mallampati score, ability to prognath, and overall airway assessment score. Obesity did not correlate with circumferential collapse at the velopharynx, or to multi-level collapse. Thyromental distance <6.5 cm was found to be statistically correlated to total epiglottic collapse (E = 2+). Friedman tongue position scores were found to be correlated to velopharyngeal collapse (p < 0.05).

CONCLUSIONS

Anesthesia airway assessment algorithms and physical exam findings do not correlate well with findings on sleep endoscopy. DISE remains the gold standard for evaluating levels of collapse and operative planning in the OSA population.

[Pyogenic granuloma on the epiglottis]

In this case report, a 78-year-old man presented with dyspnoea, globus sensation and haemoptysis. CT scan and fibre-optic laryngoscopy revealed a 2 × 3 cm tumour on the laryngeal surface of the epiglottis. The tumour was surgically removed by direct laryngoscopy and debulking. Histology showed a pyogenic granuloma with large amounts of yeasts and bacteria. Six months later the tumour recurred. Treatment with fluconazole and removal with CO2 laser was effective. After a year and a half there were no signs of recurrence.

Airway Obstruction Caused by Mucinous Material Adherent to the Epiglottis in a Patient with a Progressive Neurological Disorder: An Unusual Case of a Condition Mimicking Acquired Laryngomalacia

We herein report the successful management of a condition mimicking acquired laryngomalacia using conservative methods in an elderly man with a progressive neurological disorder. The patient developed stridor and was transferred to the intensive-care unit. Flexible laryngoscopy revealed a collapsed epiglottis during inspiration, as seen in acquired laryngomalacia, with mucinous material firmly adhered to the epiglottis. The stridor resolved after the removal of this material. Pathology revealed keratinized material, suggesting a collection of sputum or epithelial tissue. Thus, flexible laryngoscopy can differentiate the cause of airway obstruction and avoid unnecessary endotracheal intubation in patients with neurological disorders.

Epiglottic Non-Hodgkin's Lymphoma: Case Report

A locally recurrent head and neck nodal, B cell nodular, non-Hodgkin's lymphoma transformed to a diffuse histologic pattern with a peculiar bone marrow and epiglottic involvement without other apparent localizations is reported. Radiotherapy proved highly effective for local control of the epiglottic lesion but chemotherapy failed to eradicate bone marrow disease.

Inverted schneiderian papilloma of the supraglottis: Case report

Inverted schneiderian papillomas are rare benign tumors, most often arising from the sinonasal mucosa. We describe a case of a 59-year-old female with an inverted papilloma of the supraglottis. This is the first reported case of a supraglottic-presenting inverted papilloma. Although rare, this case demonstrates that these tumors should be considered during workup of supraglottic laryngeal masses. Laryngoscope, 127:2830-2832, 2017.

[Ulcers on the epiglottis caused by a nasogastric tube in three adults with severe motor and intellectual disabilities]

Nasogastric tube feeding is a common method of parenteral nutrition. We observed ulcers on the epiglottis caused by a nasogastric tube in three adults with severe motor and intellectual disabilities (SMID) during examination with a laryngeal fiberscope while swallowing. These ulcers were healed by changing the method of inserting the nasogastric tube. The patients were three men aged 25, 39, and 55 years. The muscle tone of the whole body was increased in all of the patients. Two patients had severe scoliosis, and the other patient had lordosis in the thoracic vertebrae and had received laryngo-tracheal diversion. All of the patients received intermittent or continuous respiratory care. The pharynx of the patients with severe scoliosis became thinner and the feeding tubes ran obliquely. The feeding tube in the patient who received laryngo-tracheal diversion entered the cut and closed trachea through the glottis. Ulcers were observed on the laryngeal side of the epiglottis in all of the patients. The ulcers were healed by preventing feeding tubes from running obliquely or by using the naso-gastric tube made of different materials in the patients with severe scoliosis. In the patient who received laryngo-tracheal diversion, we succeeded in avoiding the glottis by keeping his face forward while inserting the feeding tube. Then feeding tubes were changed with guidewires, and the ulcers were healed. When using nasogastric tube feeding for persons with SMID with a large increase in muscle tone and/or with severe scoliosis, adopting a method of inserting feeding tubes that avoids damaging the epiglottis with a laryngeal fiberscope is required.

[Efficacy of a Bronchofiberscope in Combination with the GlideScopee in a Difficult Airway Patient]

We present a case of securing a difficult airway in which intubation with a fiberoptic bronchoscope (FOB) assisted by the GlideScope® (GS) was effective. A 69-year-old man was scheduled to undergo laparoscopic hernia repair under general anesthesia. He had a small jaw and Grade 3 upper lip bite test in the preoperative assessment. Mask ventilation was possible following the induction of general anesthesia. Given that the glottis was not observable with the Macintosh laryngoscope (Cormack-Lehane Grade 4), laryngoscopy was per- formed with the GS, which allowed visualization of the tip of the epiglottis. Under GS monitoring, we inserted the FOB under the epiglottis and bent the tip upward to observe the lower edge of the glottis, which allowed for successful tracheal intubation. We conclude that use of the GS in combination with a FOB allows for secur- ing difficult airways that would otherwise be impossi- ble to intubate with the GS or FOB alone.

Induction chemotherapy followed by supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP) in T3NO arytenoid fixation-related glottic cancer

Induction chemotherapy followed by supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEF) in T3NO arytenoid fixation-related glottic cancer.

OBJECTIVE

Arytenoid fixation in the larynx has been considered a contraindication for performing organ preservation surgery (OPS). We present a retrospective series of cases of arytenoid fixation-related T3N0 glottic cancer treated by neoadjuvant chemotherapy followed by OPS.

MATERIAL

Retrospective review of 19 patients (from 2008 to 2012) with T3NO glottic cancer who received two cycles of neoadjuvant chemotherapy with a combination of paclitaxel, cisplatin and 5-fluoruracil (PPF), with a 21-day interval between each cycle, followed by supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP).

RESULTS

Sixteen patients with a mean age of 56.4 years received neoadjuvant chemotherapy with a clinical response (7 partial response/9 complete response) and radiologic response by computed tomography (CT) (7 partial response/7 complete response/2 cases without CT) were treated with SCPL-CHEP and removal of the arytenoid cartilage in the tumour site (10 left/6 right), bilateral neck dissection of levels II to V and searching of the Delphian node. There was one patient who died after a recurrence in the larynx and who also had an additional concomitant second primary tumour, and a second patient with a second primary tumour in the lung, who is still alive after treatment. Disease-free survival (DFS) was 82.5% at 5 years and overall survival (OS) was 80% at 5 years.

CONCLUSION

Neoadjuvant chemotherapy proved beneficial in patients waiting for surgery, helped maximize the oncologic benefit of the surgery provided (good local control using SCPL with CHEP), improved regional and distant control, minimized side effects by avoiding treatment with radiotherapy whenever possible, and proved feasible even in the presence of ipsilateral arytenoid fixation. Our results are encouraging, although a multi-centre randomized clinical trial should be performed in order to identify the true impact of this approach.

Epiglottic cyst causing dysphagia and impending airway obstruction

Laryngeal cysts are relatively rare benign lesions of the larynx. Congenital cysts can cause neonatal respiratory distress and death, but airway obstruction due to acquired cysts in adults is rare. We present a case report of 51-year-old male with dysphagia who was found to have a mobile pedunculated epiglottic cyst that intermittently caused partial obstruction of the laryngeal inlet. Patient was taken to operating room and following transoral fiberoptic intubation, endoscopic excision of this cyst was accomplished. Patient's postoperative course was uneventful.

[Clinical observation of coblation under endoscopy on epiglottis cyst]

OBJECTIVE

To evaluate the effect of the coblation under endoscopy on epiglottis cyst.

METHOD

One hundred and ninety-three patients with epiglottis cyst were treated with coblation under endoscopy. Follow-up study was performed from 1 month to 6 months after treatments.

RESULT

All 193 cases with epiglottis cyst were primary cured without serious complication and the cure rate was 100%. Moreover, the minor hemorrhage (1-5 ml) was observed.

CONCLUSION

The coblation under endoscopy on epiglottis cyst was safe, effective and minimally invasive.

[A case of epiglottic pleomorphic adenoma]

The pleomorphic adenoma of epiglottis is rare. When the tumor grows larger, some patients may have symptoms of pharyngeal foreign body sensation, but other patients have no obvious symptom. The tumor is mainly found through indirect laryngoscopy or electronic laryngoscopy. This disease can be confirmed by pathological diagnosis after tumor resection.

Transglottic laryngeal paraganglioma: a rare location for this tumor

Laryngeal paragangliomas are rare neoplasms that originate in the neural crest cells of the laryngeal paraganglia. Although the vast majority of these tumors are benign, they exhibit different types of biologic behavior that require different treatment modalities. Therefore, differentiation among these tumors is extremely important. We report a rare case of laryngeal paraganglioma that presented as a transglottic lesion in a 68-year-old man. The atypical location of the tumor led to difficulties in diagnosis and management. To the best of our knowledge, this is only the third such case to be reported in the English-language literature.

First presentation of sarcoidosis with severe obstructive sleep apnoea and epiglottic involvement

Sarcoidosis of the upper respiratory tract (SURT) is rare but well documented. We present a patient whose first presentation with sarcoidosis was with dysphonia, upper airways obstruction and severe obstructive sleep apnoea (OSA) . Systemic steroids and hydroxycholoroquine led to improvement in phonation, endoscopic appearance and upper airway obstruction with significant improvement in Apnoea Hypopnoea Index (AHI) on polysomnography.

[Combined use of the Airway Scope and gum elastic bougie for tracheal intubation in a patient with an epiglottic cyst]

A 71-year-old man with sigmoid colon cancer was scheduled for the sigmoidectomy under general anesthesia. In preoperative examination, an epiglottic cyst was found accidentally. He had no subjective symptom. Rapid induction with remifentanil, propofol, rocuronium and ephedrine was performed, and the mask ventilation was easy. The Airway Scope (AWS) was inserted at first, but it was difficult to intubate because of the epiglottic cyst. Then a gum elastic bougie (GEB) was inserted under observation by AWS monitor. GEB was passed into the trachea, and the tube was passed over the GEB into the trachea. Combined use of AWS and GEB is useful for endotracheal intubation in a patient with a epiglottic cyst.

Radiofrequency ablation of pediatric vallecular cysts

OBJECTIVE

Pediatric congenital vallecular cysts are an infrequent cause of infantile airway obstruction that can cause difficulty breathing or feeding, and lead to failure to thrive or death. There have been many different techniques proposed for effective treatment. We present three cases of congenital vallecular cyst, all excised utilizing a bipolar radiofrequency plasma ablation (RFA) device. The bipolar RFA device provides excellent hemostasis without the risk of airway fire. We offer a review of literature and a discussion of the potential advantages of this modality in treating neonatal/infantile vallecular cysts.

METHODS

Retrospective case series of three infants all between 2 and 3 months old who presented with failure to thrive due to partially obstructive vallecular cysts. The cysts were removed surgically utilizing a bipolar RFA device. Patients were followed by complications and signs of recurrence for periods ranging from 9 to 20months.

RESULTS

All cysts were excised completely in a single operation. All children are feeding well and without stridor or evidence of recurrence between 9 and 20 months postoperatively.

CONCLUSIONS

RFA appears to be an effective and safe modality for removing vallecular cysts. We were able to demonstrate complete removal of lesions in our patients. This provides an alternative to other ablative modalities in treating cystic lesions of the vallecula and larynx.

[Individualized partial laryngectomy during surgery of epiglottic carcinoma]

OBJECTIVE

To investigate an individualized operative modality of partial laryngectomy for suprahyoid epiglottis centered epiglottic carcinoma.

METHOD

Eleven cases of epiglottic squamous carcinoma which primarily focused in the suprahyoid region were included. Preoperative CT indicated that obvious margin with low density existed in the pre-epiglottic space in 3 cases, and pre-epiglottic space were involved in 8 cases, among which the arytenoid region were involved in 2 cases. An individualized partial laryngectomy was manipulated beyond the safe margin, an arytenoid epiglottic fold-plasty was performed and the remaining epiglottis was fixed to the tongue base. Adjuvant postoperative radiotherapy and chemotherapy were applied to all patients and the follow-up time lasted from 1 to 6 years with mean time of 3 years and 6 months.

RESULT

One patient died of recurrence in the tongue base after one year postoperatively, one was lost to follow-up 2 years after surgery. The overall 3-year survival rate was 81.8%. Nine patients were free from tracheal cannulation within one year postoperatively and the other two patients went on with tracheal tube assisted respiration. Aspiration gradually disappeared within 1-3 months.

CONCLUSION

Individualized partial laryngectomy in treatment of epiglottic carcinoma could preserve more laryngeal tissue and result in better laryngeal function preservation.

Epiglottic abscess: a rare cause of odynophagia

Epiglottic abscess is rare sequelae of acute epiglottitis. It occurs commonly in adult although acute epiglottitis commonly occur in children. The presentation includes fever with odynophagia. The diagnosis is based on high index of suspicion especially when oral examinations reveal normal findings. We report a case of adult epiglottic abscess which was treated with incision and drainage. The outline of management was discussed.

Asymptomatic epiglottic cyst: a rare cause of unanticipated difficult intubation

Cysts of epiglottis are rare. Following induction of anesthesia, asymptomatic cysts may lead to unanticipated difficulty in ventilation or intubation or both and can be potentially life threatening in such situations.