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Abstract Background This study aimed to perform a comprehensive morphometric analysis of the epiglottis using cone-beam computed tomography (CBCT) images, including the determination of epiglottis dimensions, the investigation of shape variations, and the assessment of their relationship with gender and age. Methods A retrospective analysis was conducted on high-quality CBCT images from 100 patients, obtained using the NewTom 5G system. In CBCT images, epiglottis thicknesses (right, midline, left) and horizontal angle at three levels (suprahyoid, hyoid, infrahyoid) were measured in axial sections, while the length and vertical angle of epiglottis were measured in midsagittal view. Epiglottis shapes were identified through 3D visualization. Results The midline epiglottis thicknesses were 4.68 mm at the suprahyoid level, 5.51 mm at the hyoid level, and 6.80 mm at the infrahyoid levels. Epiglottis thicknesses and length were statistically significantly greater in males. Of the 100 patients, 51 had a normal curvature, 41 had a flat epiglottis, and 8 had an omega epiglottis. The omega-shaped epiglottis was significantly longer compared to both the flat and normal curvature types (p = 0.011). There was a positive correlation between age and epiglottis thicknesses at the suprahyoid level and horizontal angles at three levels. Conclusions This study visualizes epiglottis morphology and uncovers significant morphometric differences. Males exhibit greater epiglottis thickness and length compared to females, while the omega-shaped epiglottis is notably longer than other types. These findings underscore the need for further investigation into the clinical relevance of these morphometric differences, particularly in improving airway management and refining approaches to swallowing function.

This dataset comprises a comprehensive collection of videos and images illustrating the fluid dynamics of swallowing and aspiration in a patient-specific pharyngolaryngeal model with varying epiglottis angles. The data also includes the physical properties of the fluids used, comprising dynamic viscosity, surface tension, and contact angle. Videos under varying swallowing conditions were collected to investigate the mechanisms underlying aspiration. The study utilized a biomechanical swallowing model developed using transparent casts of an anatomically accurate pharyngolaryngeal structure. Fluorescent dye was used to visualize the liquid flow dynamics from both side and back views. The dataset includes videos for two types of liquids, water and a 1% w/v methylcellulose aqueous solution, evaluated under two dispensing speeds (fast and slow) and two dispensing locations (anterior and posterior) across four epiglottis angles (30° up-tilt, 0° horizontal, 45° down-tilt, and 80° down-tilt). Additionally, the dataset includes photos of the pharyngolaryngeal model setup, photos of the epiglottis models used, and STL files for both the pharyngolaryngeal model and the epiglottis 3D models.The videos document the distinct flow patterns and frequent aspiration sites identified during the experiments, including the interarytenoid notch, the cuneiform tubercular recess, and the vallecula. These data are valuable for researchers aiming to understand the etiology of dysphagia and can be reused to validate computational models, guide future experimental designs, and inform clinical diagnostics and treatment strategies. The dataset is organized into folders based on the epiglottis angles, dispensing speeds, and locations, as well as liquid types. This organization facilitates easy access and analysis for researchers in biomedical engineering, clinical research, and computational biology. The data provide a rich resource for further investigation into swallowing mechanics and the development of etiology-based interventions for dysphagia management.

Background Epiglottis abnormality is rare condition and can lead embarrassing intubation to anesthesiologists. Here, we reported a case of successful management in a patient with unexpected hidden vocal cords due to epiglottis adhesion to the posterior wall of the laryngeal cavity. Case A 60-year-old female with no underlying disease was scheduled for general anesthesia to undergo a left-cochlear implant operation. After the induction procedure (including intravenous injection of rocuronium), an epiglottic adhesion to the posterior wall of the laryngeal cavity and invisible vocal cords were confirmed. Although the first trial of intubation failed, the patient’s airway was successfully managed using a technique that combined a video-styletscope (Markstein Sichtec Medical Co., 5.0 mm ID) with a video-laryngoscope (Insighters®, Cedrus Medical). Conclusions Anesthesiologists may unexpectedly encounter asymptomatic abnormal airways with unknown causes. In such a situation, it is essential to establish a strategy and to select appropriate device according to patient circumstances.

Impaired swallowing, or dysphagia, significantly affects patients' well-being and health. Nearly half of the patients with head and neck cancers experience dysphagia or aspiration following radiation therapy or surgery. However, current dysphagia management approaches are primarily symptom-based rather than etiology-specific, owing to a lack of clear understanding of aspiration mechanisms. This study aimed to understand the mechanisms of aspiration in an anatomically accurate pharyngolaryngeal model at different epiglottis angles. A biomechanical swallowing model was developed using transparent casts, and liquid flow dynamics were visualized using fluorescent dye from side and back views. Two liquids and two dispensing conditions were evaluated for their roles in aspiration. The results demonstrated distinct flow dynamics between water and a 1 ​% w/v methylcellulose aqueous solution and, to a lesser extent, between fast and slow dispensing for the same liquid. Three frequent aspiration sites were identified, including the interarytenoid notch, the cuneiform tubercular recess, and the vallecula, corresponding to aspiration mechanisms of notch overflow, recess overflow, and creeping flow, respectively. The angle of the epiglottis influenced flow dynamics in at least three ways: by facilitating gravity-assisted fluid movement, redistributing flow through the gap between the epiglottis tip and pharyngeal wall, and affecting creeping flow via the angle between the epiglottis base and hypopharynx. Slow dispensing of water to the anterior oropharynx resulted in a significantly high aspiration rate with a downward tilted epiglottis due to concurrent tubercle-recess overflow and vallecular creeping flow. The biomechanical model can serve as a testing platform for better understanding aspiration mechanisms and developing etiology-based strategies before and after treatments for head and neck cancers.

Abstract Understanding the mechanisms underlying dysphagia is crucial in devising effective, etiology-centered interventions. However, current clinical assessment and treatment of dysphagia are still more symptom-focused due to our limited understanding of the sophisticated symptom-etiology associations causing swallowing disorders. This study aimed to elucidate the mechanisms giving rise to penetration flows into the laryngeal vestibule that results in aspirations with varying symptoms. Methods: Anatomically accurate, transparent throat models were prepared with a 45° down flapped epiglottis to simulate the instant of laryngeal closure during swallowing. Fluid bolus dynamics were visualized with fluorescent dye from lateral, rear, front, and endoscopic directions to capture key hydrodynamic features leading to aspiration. Three influencing factors, fluid consistency, liquid dispensing site, and dispensing speed, were systemically evaluated on their roles in liquid aspirations. Results: Three aspiration mechanisms were identified, with liquid bolus entering the airway through (a) the interarytenoid notch (notch overflow), (b) cuneiform tubercle recesses (recess overflow), and (c) off-edge flow underneath the epiglottis (off-edge capillary flow). Of the three factors considered, liquid viscosity has the most significant impact on aspiration rate, followed by the liquid dispensing site and the dispensing speed. Water had one order of magnitude higher aspiration risks than 1% w/v methyl cellulose solution, a mildly thick liquid. Anterior dispensing had higher chances for aspiration than posterior oropharyngeal dispensing for both liquids and dispensing speeds considered. The effects of dispending speed varied. A lower speed increased aspiration for anterior-dispensed liquids due to increased off-edge capillary flows, while it significantly reduced aspiration for posterior-dispensed liquids due to reduced notch overflows. Visualizing swallowing hydrodynamics from multiple orientations facilitates detailed site-specific inspections of aspiration mechanisms.

Swallowing disorders, or dysphagia, can lead to bolus aspiration in the airway, causing serious adverse health effects. Current clinical interventions for dysphagia are mainly empirical and often based on symptoms rather than etiology, of which a thorough understanding is still lacking. However, it is challenging to study the swallowing process that involves sequential structural motions and is inaccessible to standard visualization instruments. This study proposed an in vitro method to visualize swallowing hydrodynamics and identify the fundamental mechanisms underlying overflow aspirations. An anatomically accurate pharynx–epiglottis model was developed from patient-specific CT images of 623 µm isotropic resolution. A compliant half-pharynx cast was prepared to incorporate dynamic structures and visualize the flow dynamics in the mid-sagittal plane. Three locations of frequent overflow aspiration were identified: the epiglottis base, cuneiform tubular recesses, and the interarytenoid notch. Water had a consistently higher aspiration risk than a 1% w/v methylcellulose (MC) solution. The contracting–relaxing pharynx and flapping epiglottis spread the liquid film, causing a delayed esophageal entry and increased vallecular residual, which was more pronounced with the MC solution. Dispensing the liquid too slowly resulted in water aspiration, whereas this was not observed with the MC solution. An incomplete epiglottis inversion, such as horizontal or down-tilt 45°, aggravated the aspiration risks of water. This study suggests that it is practical to use anatomically accurate respiratory–digestive models to study the swallowing process by incorporating varying physiological details.

Abstract Objectives The growth and development of the epiglottis and preepiglottic space (PES) of the human larynx as it acquires the vocal tract were investigated. Methods Three newborns, one infant, four children (2, 7, 8, and 12 years old), and two adult normal larynges were investigated and compared using the whole organ serial section technique. Results The newborn PES occupied a small area just anterior to the epiglottis. It was composed of immature adipose tissue and areolar tissue. The epiglottis lay on a somewhat horizontal axis and is partially obscured behind the hyoid bone. The hyoid bone overlapped the thyroid cartilage, partially obscuring the superior thyroid notch. The newborn epiglottic cartilage was immature elastic cartilage, and the elastic fiber component was sparse. In the first 8 years of life, as the PES grew, the PES was located not only anterior to but also posterolateral and inferolateral to the epiglottic cartilage and thyroepiglottic ligament. Meanwhile, the epiglottic cartilage matured. Conclusions In order to develop the vocal tract for speech production, it is reported that the human larynx descends as the child grows in the first 9 years of life. This study showed that the PES, occupying a small area just anterior to the epiglottis, grew and existed astride the epiglottis as the larynx descended and the vocal tract developed. Consequently, its distribution allows the epiglottis to more effectively play the role of retroflection during swallowing in order to prevent aspiration. The human speech faculty likely develops in conjunction with swallowing physiology.

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

Abstract Background Compared to other intravenous anesthetics, availability of a specific antagonist flumazenil is a clear advantage of remimazolam. We report a patient who could be rapidly woken up when laryngoscopy and tracheal intubation were unexpectedly difficult. Case presentation A 62-year-old man was scheduled to have resection of a small gingival tumor. Preoperative airway examination was unremarkable except for an omega-shaped epiglottis. Anesthesia was induced with remifentanil/remimazolam infusion and rocuronium. A small omega-shaped edematous epiglottis precluded identification of glottis. Consciousness and spontaneous ventilation were rapidly restored after administration of flumazenil and sugammadex. Tracheostomy was done under local anesthesia while the patient breathed spontaneously. Conclusions Remimazolam can be a reasonable induction agent when there are concerns regarding airway management. Avoiding repeated airway manipulations is extremely important to prevent deterioration into a “cannot intubate, cannot ventilate (CICV)” emergency.

Angiofibroma is a non-encapsulated, highly vascular tumor that usually originates in the nasopharynx. Laryngeal cases of extranasopharyngeal angiofibroma (ENA) are a very rare pathology, especially in children. Only eight ENA laryngeal cases have been described in the literature, and only one of them is a pediatric case. In this report we present an 11-year-old child with epiglottic ENA resected with transoral endoscopic ultrasonic surgery (TOUSS) with review of the literature. Because of reccurrence after five months he underwent re-excision with CO2 laser. Recurrences in ENA are infrequent, but as demonstrated in our case, close endoscopic follow-up is mandatory in this location. Endoscopic hemostatic procedures like TOUSS and CO2 laser ensure bloodless surgery for the management of this type of vascular laryngeal tumors

Abstract 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.

PurposeIt is unknown if direct epiglottis lifting or conversion to hyperangulated videolaryngoscopes, or even direct epiglottis lifting with hyperangulated videolaryngoscopes, may optimize glottis visualization in situations where Macintosh videolaryngoscopy turns out to be more difficult than expected. This study aims to determine if the percentage of glottic opening (POGO) improvement achieved by direct epiglottis lifting is non-inferior to the one accomplished by a conversion to hyperangulated videolaryngoscopy in these situations.MethodsOne or more optimization techniques were applied in 129 difficult Macintosh videolaryngoscopy cases in this secondary analysis of a prospective observational study. Stored videos were reviewed by at least three independent observers who assessed the POGO and six glottis view grades. A linear mixed regression and a linear regression model were fitted. Estimated marginal means were used to analyze differences between optimization maneuvers.ResultsIn this study, 163 optimization maneuvers (77 direct epiglottis lifting, 57 hyperangulated videolaryngoscopy and 29 direct epiglottis lifting with a hyperangulated videolaryngoscope) were applied exclusively or sequentially. Vocal cords were not visible in 91.5% of the cases with Macintosh videolaryngoscopy, 24.7% with direct epiglottis lifting, 36.8% with hyperangulated videolaryngoscopy and 0% with direct lifting with a hyperangulated videolaryngoscope. Conversion to direct epiglottis lifting improved POGO (mean + 49.7%; 95% confidence interval [CI] 41.4 to 58.0; p

Dermoid cysts are developmental anomalies that occur during midline fusion in embryological life. It is known that they can also be acquired as a result of traumatic and iatrogenic implantation. Laryngeal involvement of dermoid cysts has been reported very rarely in the literature. This report presents a case with multiple dermoid cysts originating from the epiglottis. A 59-year-old male patient was admitted to our clinic with complaints of foreign body sensation in the throat and dysphagia. Multiple cystic lesions originating from the epiglottis were observed in the laryngeal examination of the patient. After radiological examinations, the cysts were completely excised by endolaryngeal surgery. After excision of the lesions, which were reported as dermoid cysts, all complaints of the patient regressed, and no recurrence was observed in the 6th month after the operation and his follow-up continued. Dermoid cysts originating from the epiglottis are very rare, but they should be kept in mind in the differential diagnosis of epiglottis lesions.

Background: Penetrating trauma to the larynx is a rare phenomenon with a high risk of mortality and morbidity due to the density of vital structures in the area (Demetriades et al., 1996). Most commonly, this type of injury is due to a gunshot wound or knife injury (Snow and Ballenger, 2003). In cases of suicidal cutthroat injury, it is relatively rare to penetrate the airway (Symbas et al., 1976). Case report: We present a case of self-penetrating trauma to the anterior neck allowing access for direct laryngeal visualization and transcervical intubation in the field. We describe the immediate workup, surgical intervention, and postoperative management. We focus on managing postoperative cough, secretion management, decannulation, and resultant dysphagia. Conclusion: Penetrating laryngeal trauma resulting in airway transection is a rare but potentially fatal phenomenon in which airway management and aggressive post-operative care for severe coughing and dysphagia should be performed to help improve patient outcomes.

Background/purpose: Proper breathing is essential to healthy growth and development of children. The present study aimed to investigate changes in the pharyngeal airway space in primary-school children. Materials and methods: Cephalometric radiographs were obtained from 93 primary-school children, who were divided into three age groups (Group I, aged 7–8 years; Group II, aged 9–10 years; and Group III, aged 11–12 years). Landmarks identified on each cephalogram included the tip of the uvula (U), hyoid bone (H), and epiglottis (E). Linear and angular measurements comprised nasopharyngeal airway (NP); PS (shortest distance from the soft palate to the pharyngeal wall); UP (distance from the tip of the uvula to the pharyngeal wall); TS (shortest distance from the posterior tongue to the pharyngeal wall); EP (distance, parallel to the X-axis, from the epiglottis to the pharyngeal wall). Statistical analysis was performed using one-way analysis of variance and Pearson correlation tests. Results: Group III had the highest values for all the variables. The three groups exhibited significant differences for all pharyngeal airway variables, except for EP. The three groups had significantly different vertical U, H, and E. There were positive correlations between age and NP, PS, UP, and TS; however, no significant correlation was observed between age and EP. Age significantly correlated with the vertical U, E, and H. Correlations between age and the horizontal U, E, and H were nonsignificant. Conclusion: Among primary-school children from various grades, age significantly correlated with all pharyngeal airway variables, except with EP.

Along with the development of diagnostic techniques, many studies have been conducted to find the anatomical causes of obstructive sleep apnea (OSA). The velum, oropharynx, tongue base, and epiglottis have been widely considered to be the common obstruction sites. However, the role of the epiglottis in sleep apnea is poorly understood compared to the other anatomical sites. The epiglottis causes OSA either alone or simultaneously with other obstruction sites. We have here reviewed the epidemiology, pathophysiology, diagnosis, and treatment of epiglottic collapse in patients with OSA based on the literature published to date.

Abstract Background We present the first case of a patient with obstructive sleep apnea syndrome (OSA), where drug induced sleep endoscopy was helpful to suspect a non-acid reflux disease and showed an improvement in a swollen epiglottis after treatment. Patient ameliorated significantly his disease only with medical therapy. Case presentation A 54-year-old man without significant anatomical findings with obstructive sleep apnea syndrome and non-acid gastroesophageal reflux disease (GERD) disease whose Apnea- hypopnea index (AHI) was significantly reduced with the intake of 500 mg of sodium alginate twice a day for 6 months. Conventional digestive tests such as esophagoscopy and simple- and double-channel 24-h pH-metry suggested mild GERD. Conventional proton-pump inhibitor treatment with pantoprazole (40 mg daily) was started without any improvement in his sleep. Multichannel intraluminal 24-h impedanciometry indicated the presence of severe pathological GER of gaseous origin. The patient’s AHI decreased from 25.3 at baseline to 8 after treatment with sodium alginate. A drug-induced sleep endoscopy study showed the changes before and after this treatment and was helpful for the diagnosis. Conclusions Thus, medical treatment can be a therapeutic option in some patients with OSA. Multichannel 24-h impedanciometry should be performed when nonacid GERD is suspected.

Background The direct entry of the camera under the epiglottis may provide a better view of the glottis than the indirect lifting of the epiglottis by placing the Macintosh blade tip on the vallecula when using the video laryngoscope. This study aimed to compare the efficiency of two different methods of lifting the epiglottis during the visualization of glottis using video laryngoscopy in the same patient. Methods This prospective study enrolled 60 patients who underwent general anesthesia with tracheal intubation. In each patient, glottic views were obtained by directly (group DE) and indirectly lifting the epiglottis (group IE). These two methods were compared using the modified Cormack and Lehane grade and the percentage of glottis opening (POGO) score as assessment parameters. Results Modified Cormack and Lehane grade showed a significant difference between the groups DE and IE (P = 0.004). The difference in the POGO score between the groups DE and IE was also statistically significant (87.5% and 64.4%, respectively; P < 0.001). Conclusions Our results, therefore, revealed that the method of directly lifting epiglottis was better at exposing glottis than the method of indirectly lifting epiglottis using a video laryngoscope.

Histoplasmosis is an endemic disease mainly occurring in North America and is rare in China. Confirmation of histoplasmosis should be based on a compatible clinical scenario and a positive culture or histopathology. However, there are still many cases that are misdiagnosed or missed, especially in individuals from non-endemic areas. In recent years, metagenomic next-generation sequencing (mNGS) has led to the accurate and timely diagnosis of some rare and complicated infectious diseases. We describe the case of a 27-year-old Chinese man who had chronic progressive pulmonary lesions without any symptoms for more than 1 year, until the lesions reached the epiglottis and led to progressive pharyngeal pain. There were no positive results from bronchoalveolar lavage fluid (BALF) and epiglottis tissue cultures, or from epiglottis and lung pathological examinations, but mNGS was able to identify Histoplasma capsulatum in the epiglottis tissues and BALF as the cause of the lesions. The patient was treated successfully with itraconazole.

Abstract Background Downfolding of the epiglottis into the laryngeal inlet is considered to be a rare complication of tracheal intubation. We describe a case of epiglottic downfolding during tracheal intubation using a McGrath videolaryngoscope (McGRATHTM MAC). Case presentation A 44-year-old female was scheduled for breast reconstruction surgery. Intubation was performed using a McGrath videolaryngoscope. After intubation, videolaryngoscopy revealed that the epiglottis was inverted and folded down into the laryngeal inlet. We elevated the larynx anteriorly using the McGrath videolaryngoscope, enabling the downfolded epiglottis to be pulled out from the laryngeal inlet and restored to its original position. After surgery, the patient was extubated without any complications. Conclusions When using the McGrath videolaryngoscope, both glottic exposure similar to that achieved with the Macintosh laryngoscope and careful observation of the epiglottis should enable the prevention, detection, and treatment of epiglottic downfolding into the laryngeal inlet.

Introduction. Currently, there is a tendency for a number of post-intubation patients to develop post-tracheostomic cicatricial stenosis of the trachea. This dictates a need for the improvement of surgical and anaesthesiologic approaches to intubation management. Objective: Analysis of the specific parameters of anesthesia for cervical tracheal resection in patients with stenosis of the trachea without its intubation.Subjects and methods. We analyzed 12 cases of circular resection of the trachea due to benign stenosis. The degree of anesthetic risk was as follows: 11 patients – ASA 3, 1 patient – ASA 4. Tracheal stenosis persisted for 14±6 months before it was resected (Me 4, Min 1, Max 67). The length of the resected part of the trachea was 27±3 mm (Me 25, Min 15, Max 40), duration of surgery – 159±9 min (Me 160, Min 65, Max 240). The anesthesia strategy included the insertion of the I-Gel supraglottic airway device with a jet ventilation catheter put through the I-Gel. Temporary stenting of the stenosis zone of the trachea before surgery (if necessary) instead of bougienate was an important component of the anesthesia strategy. Mandatory use of sedation (dexmedetomidine) is suggested before and within 12 hours after surgery.Results. This strategy can be successfully implemented if the minimum diameter of the tracheal stenosis exceeds 7 mm (the jet ventilation catheter is necessary to be applied through this lumen and a fine bronchoscope used to monitor the state of the catheter tip). Preliminary stenting with metal stents was performed in 5 patients. The I-Gel lumen was wide enough to manipulate a flexible endoscope, a catheter guide was inserted for jet ventilation, and then the catheter itself was placed. The use of high-frequency ventilation mask it advisable to ensure adequate gas exchange at all stages of the surgery. Sedation with dexmedetomidine reduced the patient’s discomfort after the surgery due to the fixation of the patient’s head with stitches in a “nodding” position, which reduced anastomosis tension. In all 12 patients, this anesthesia strategy was successful and provided a more favorable environment for surgeons compared to the classical approach with the use of an endotracheal tube. In all patients, anastomosis healed by primary tension with no complications.Conclusion. The use of a supraglottic airway device, dexmedetomidine, and temporary stenting of the stenotic part of the trachea allow the surgeon to avoid tracheal intubation during circular resection and expand the range of anesthesiological tools during tracheal surgery.

Objective To evaluate the longitudinal changes of swallowing kinematics based on videofluoroscopic swallowing studies (VFSSs) in subacute stroke patients grouped according to the method of dietary intake. Methods Sixty-nine subacute stroke patients who had taken at least 2 successive VFSSs were included. Subjects were allocated into 3 groups according to the degree of swallowing function recovery—not improved group (tube feeding recommended to patients at both studies), improved group (tube feedings recommended initially to patients and oral feeding recommended at follow-up study), and well-maintained group (oral feeding at both studies recommended to patients). Initial VFSS was performed during the subacute stage of stroke, 1 to 12 weeks after the onset of stroke, and follow-up VFSS was performed at least once. Kinematic variables were calculated by two-dimensional motion analysis of multiple structures, including the hyoid bone, epiglottis, and vocal cord. Changes of kinematic variables were analyzed in serial VFSSs. Results At the initial VFSS, the well-maintained group showed significantly larger angles of epiglottic folding than the not improved group, while at the follow-up VFSS, the improved and the well-maintained groups showed significantly larger epiglottic folding angles than the not improved group. The distribution of epiglottic folding angles was in a dichotomous pattern, and each cluster was related to the swallowing function. Conclusion This study showed that improved epiglottic folding angles are associated with the recovery of the swallowing process and suitability for oral feeding among various kinematic variables in subacute stroke patients.

Background and Aims: Oropharyngeal seal pressure (OSP) achieved by a supraglottic airway device holds due importance as it indicates the feasibility of positive pressure ventilation, the degree of airway protection from supra-cuff soiling and also relates to postoperative morbidity. The primary outcome measure was to assess and compare OSP in different head and neck positions with Baska mask® and I-gel™. Secondary outcome measures were to compare peak inspiratory pressure (PIP), exhaled tidal volume (ETV), ease of insertion, time taken for insertion, number of attempts, intraoperative manipulations, and postoperative airway morbidity with both the devices. Materials and Methods: Seventy consenting adults scheduled for a variety of surgical procedures under general anesthesia were allocated to Group B and Group G using Baska mask® and I-gel™ respectively. All statistical calculations were done using SPSS (Statistical Package for the Social Science). The comparison of quantitative variables between the study groups was done using Student t-test and within the variables was done by paired t-test. For comparing categorical data, Chi-square (χ2) test was performed. Results: OSP was significantly higher in group B than in group G in all head and neck positions (neutral 33 ± 2.8 vs. 23.2 ± 1.8, flexion 35.5 ± 2.5 vs. 25.2 ± 1.6, extension 30.6 ± 2.7 vs. 21.4 ± 1.7, right lateral 32.6 ± 2.8 vs. 23.0 ± 1.5. left lateral 32.6 ± 2.7 vs. 23.1 ± 1.7 cm H2O, respectively) (P = 0.000). PIP increased significantly in group G as compared to group B in flexion. (P = 0.009). Baska mask® had significantly higher ETV in flexion compared to I-gel™. (P = 0.009). Conclusion: Baska mask® may provide a useful alternative to I-gel™ where the glottic seal has precedence over ease of insertion.

Diagnosis of the Human Immunodeficiency Virus (HIV) remains challenging due to non-specific clinical presentations and mostly flu-like symptoms, e.g., fever, headache, sore throat, and general weakness. Oral lesions, such as oral candidiasis and Kaposi sarcoma, are also frequently associated with HIV infection, whereas laryngeal manifestations are rare. We report two cases of newly diagnosed HIV patients with clinical presentations of sore throat, and endoscopy revealed an epiglottic ulcerative tumor-like lesion. A laryngomicrosurgical biopsy of the lesions was performed for persistent symptoms and suspicion of malignancy. The result revealed acute and chronic inflammation without a conclusive pathology diagnosis. Further laboratory analysis was arranged in consideration of autoimmune diseases, Epstein–Barr virus (EBV), and HIV infection due to their persistent and atypical symptoms. The results were positive for HIV infection. These patients were treated successfully with antiviral treatment and the laryngeal symptoms improved within weeks. In patients with idiopathic and persistent epiglottitis or an epiglottic ulcer after medical treatment, HIV infection needs to be considered as a potential etiology in order to institute proper treatment.

The critical role of epiglottis in airway narrowing contributing to obstructive sleep apnoea (OSA) and continuous positive airway pressure (CPAP) intolerance has recently been revealed. This systematic review was conducted to evaluate available surgical treatment options for epiglottic collapse in adult patients with OSA. The Pubmed and Scopus databases were searched for relevant articles up to and including March 2022 and sixteen studies were selected. Overall, six different surgical techniques were described, including partial epiglottectomy, epiglottis stiffening operation, glossoepiglottopexy, supraglottoplasty, transoral robotic surgery, maxillomandibular advancement and hypoglossal nerve stimulation. All surgical methods were reported to be safe and effective in managing selected OSA patients with airway narrowing at the level of epiglottis. The surgical management of epiglottic collapse can improve OSA severity or even cure OSA, but can also improve CPAP compliance. The selection of the appropriate surgical technique should be part of an individualised, patient-specific therapeutic approach. However, there are not enough data to make definitive conclusions and additional high-quality studies are required.

Introduction Primitive neuroectodermal tumors (PNETs) are malignant tumors comprised of small round cells of neuro-ectodermal origin that affect soft tissue and bone. Though the occurrence of pPNETs in the head and neck region is rare, these are aggressive malignant tumors, and long-term survival rates following diagnosis remain poor. Case Report In the present case, a tumour was located in larynx (as globular/cystic mass of epiglottis) of the patient and was diagnosed as pPNET. Immunohistochemical analysis indicated that tumor cells were positive for CD99 and NSE, focally positive for EMA but negative for synaptophysin and chromogranin. The mass was surgically excised with negative margins. In post op period patient was planned for post-op chemotherapy and radiotherapy. Conclusion pPNETs are very rare in head and neck region. Significant advances in the neoadjuvant and adjuvant chemotherapeutic regimens, as well as improved facility in diagnosing these tumors through cytogenetic and immunohistochemical analysis improves the long-term disease-free survival.

Proper laryngeal anatomy is crucial for airway protection. Congenital malformations of the airway are one cause of respiratory distress in children. An almost 5 month old male presented with increased work of breathing and worsening cough. Laryngoscopy showed the entire lingual surface of the epiglottis was tethered/compressed/grown to the base of tongue and was curled into a slight omega-shape. The arytenoid cartilages also hooded the glottis. The patient had airway collapse and did not have any visible tracheal rings consistent with severe tracheomalacia. A wedge-sling combination for sleeping, continuation of reflux medications, and follow up with the nutrition and feeding team were recommended. Direct laryngoscopy follow-up, sixteen months later, revealed floppy shortened epiglottis with more disconnect between the base of tongue and epiglottis. Moderate tracheomalacia with posterior collapse and right mainstem lateral collapse was also noted, with nearly complete resolution of his symptoms.

Floppy epiglottis in an adult is rare and often pathological. Airway obstruction caused by floppy epiglottis in an adult is rarely reported. Neck mass, however, can affect the airway in many ways; however, inducible upper airway obstruction by extra-laryngeal neck mass is hardly been reported. In most of the instances of inducible laryngeal obstruction, the tumor is found in and around the laryngeal inlet. Herein, we report such an unusual incident happened to a 40-year-old gentleman, a case of oral carcinoma for 3 months and a rapidly increasing swelling (6 × 5 cm) over the right side of the neck for 8 days. He presented to us for emergency tracheostomy with the feature of acute upper airway obstruction, unable to lie down; and having difficulty in breathing, desaturation, and chocking even in propped up position. The case highlights the importance of clinical findings and difficulties faced for airway management in such patients.

Introduction Primitive neuroectodermal tumors (PNETs) are malignant tumors comprised of small round cells of neuro-ectodermal origin that affect soft tissue and bone. Though the occurrence of pPNETs in the head and neck region is rare, these are aggressive malignant tumors, and long-term survival rates following diagnosis remain poor. Case Report In the present case, a tumour was located in larynx (as globular/cystic mass of epiglottis) of the patient and was diagnosed as pPNET. Immunohistochemical analysis indicated that tumor cells were positive for CD99 and NSE, focally positive for EMA but negative for synaptophysin and chromogranin. The mass was surgically excised with negative margins. In post op period patient was planned for post-op chemotherapy and radiotherapy. Conclusion pPNETs are very rare in head and neck region. Significant advances in the neoadjuvant and adjuvant chemotherapeutic regimens, as well as improved facility in diagnosing these tumors through cytogenetic and immunohistochemical analysis improves the long-term disease-free survival.

Tuberculosis represents a global health challenge and is one of the leading infectious killers, with over a million people succumbing to it every year. While the disease is primarily prevalent in developing countries, where 95% of cases and deaths occur, doctors around the globe need to be able to recognize its diverse clinical manifestations in order to initiate appropriate treatment early. The granulomatous infection caused by Mycobacterium tuberculosis typically affects the lungs, but isolated abscesses in the head and neck region can be a less common presentation of the disease, potentially resulting in dysphagia, odynophagia, voice changes, neck swelling, bone erosion, and even life-threatening respiratory distress requiring tracheostomy. Here, characteristic imaging findings and potential surgical options are discussed.

The follicular variant of peripheral T-cell lymphoma, not otherwise specified, is very rare. Primary epiglottic follicular variant of peripheral T-cell lymphoma is extremely rare in clinical practice. Here, we report the first case of a follicular variant of peripheral T-cell lymphoma not otherwise specified in a 44-year-old Chinese man, who presented with a tumor in the middle of the epiglottis tongue surface. Microscopically, the tumor had a vague nodular growth pattern and the morphology of the nodules was different from each other at low power. Atypical lymphoid cells were medium to large in size and had round nuclei, with an irregular nuclear membrane, distinct nucleoli, and rapid mitotic activity. Plasma cells were found surrounding the nodules. The tumor cells were positive for follicular helper T-cell markers (CD10, PD-1, CXCL13, and BCL-6). The EBER was negative by in situ hybridization. Polymerase chain reaction-based analysis showed monoclonal rearrangements of TCRβ, TCRγ, and polyclonal rearrangements of IgH, IgK, and IgL. The clinical and imaging features and the prognostic factors of FV PTCL-NOS remain poorly understood. Thus, investigation of more cases and longer follow-up is necessary to understand the disease and to identify the best treatment to improve prognosis.

Aplasia of the epiglottis is a rare airway abnormality requiring airway and feeding interventions. We report a case of bronchiectasis in the setting of congenital aplasia of the epiglottis, secondary to early‐life aspiration events. Compensatory mechanisms for airway protection likely develop later in life.

Purpose: The current study aimed to systematically evaluate the sonoanatomy of floor of the mouth and upper airway using protocol-based ultrasonography (USG); and to assess the feasibility of imaging the valleculae and pyriform fossae. Materials and Methods: An institutional prospective observational study was planned on fifty volunteers of all ages and both sexes, attending outpatient department for nonairway-related diseases. Protocol for ultrasonographic systemic evaluation was designed before starting the trial. All the patients were positioned supine with neck extended (sniffing position), seven steps of ultrasonographic protocol were followed and visualization of structures denoted in each step was documented. Furthermore, time taken to complete each scan was noted. Results: The USG was completed, and checklist successfully followed in all cases. Floor of mouth structures was easy to evaluate and visualized with ease in all the cases. Epiglottis was visualized in 100% cases in transverse plane. Valleculae and pyriform fossae were identified in 82% and 90% of the cases, respectively, and they appeared either as paired air-filled round structures or air-lined linear structures. Complete visualization of vocal cords was seen in 78% females and 63% males. The average time taken to complete the protocol-based study was 10.4 ± 1.4 min. Conclusions: Application of protocol-based USG for upper airway can allow the examination of structures from tongue to thyroid cartilage in a thorough, convenient, and timely manner. The air filled/lined structures such as valleculae, pyriform fossae, and vocal cords can be visualized in majority of the cases.

Background and Objective: Numerous anatomical abnormalities or pathological conditions can cause upper airway obstruction in obstructive sleep apnea syndrome (OSAS). Muller’s maneuver (MM) is one of diagnostic modalities investigating the obstruction site in patients with OSAS. This study aimed to investigate the obstruction sites of patients with OSAS based on MM. Materials and Methods: This was a case-series study. A total of 145 patients were enrolled in this study. The awake MM (a flexible fiberoptic endoscopy of the upper airway while patients perform forced inspiration against a closed oral and nasal airway) was performed by a single surgeon with the patient in a supine position. Endoscopic findings were classified using the modified velum, oropharyngeal lateral walls, tongue base, and epiglottis (VOTE) classification criteria. Results: Mean ± standard deviation age of patients was 41.5 ± 10.1 years old. Mean respiratory disturbance index was 29.7 ± 24.3/hours. The most common site of obstruction in all patients was velum. About 72% of the patients had more than 75% obstruction in the velum area while most patients had < 50% obstruction in oropharyngeal lateral walls (41.4%) and tongue base (55.2%). 69% of the patients had no obstruction in epiglottis according to the modified VOTE classification. Conclusion: Simple awake diagnostic test before surgery would help physicians to identify obstruction sites of OSAS patients.

The measurement system for the pressure between the blade of a laryngoscope and the upper airway tract during orotracheal intubation has been investigated with a film of microcapsules. Two types of the laryngoscope were used in the study: Wis-Foregger and Mac-Intosh. The film is attached on the surface of the blade of the laryngoscope. The measurement was applied to 20 cases of the orotracheal intubation. In the pressed part of the film, the microcapsules burst and release chemicals, which react with chemicals out of microcapsules and show a red color. The color density was photoelectrically measured, and converted to the pressure value in three regions on the blade; the epiglottis, the tongue, and the upper incisor. The results show that the pressures are 1.2±0.6 MPa on the epiglottis, 0.8±0.4 MPa on the tongue, and (11±3)×10 MPa on the upper incisor, and that the pressures on the epiglottis are 2.0±0.3 MPa in bled cases, and 0.8±0.4 MPa in non-bled cases.

Many species of opossums are created and used in laboratories, opening a wide field for studying and acquiring knowledge about the habits, diseases, diet and reproduction of these animals. The research aimed at describing the macroscopic and microscopical morphology of the trachea and larynx of opossums. In this study, five opossums (Didelphis sp.) were used. The trachea and larynx of the opossums were extracted, measured and processed by histology routine and dyed with Hematoxiline eosine, Picrosirius and Masson´ Trichrome. The larynx can be divided into: cricoid in a "V"-like shape, thyroid in a shield-like shape, arytenoid in shell-like shape, and epiglottis shaped like sheets, the first three structures showed hyaline cartilage, and the last structure showed elastic cartilage. The trachea showed a cylindrical form and it consists of 25 cartilaginous incomplete rings in a "C"-like shape, similar to amphibians, snakes, lizards and pigs; and different from domestic animals.

Dermoid cysts arising from the head and neck region are rare, slow-growing, and well-circumscribed neoplasms. Symptoms are non-specific and usually related to the size and the location of the lesion. A dermoid cyst of the epiglottis is extremely rare. To the best of our knowledge, only one case has been previously reported in the English literature. In this study, a case of a dermoid cyst arising from the epiglottis was presented as an extremely rare clinical condition. The characteristics, differential diagnosis, and treatment of the disease are summarized.

Lightwand-guided intubation is a semi-blind technique that takes advantage of the anterior location of the trachea in relation to the oesophagus. Fibreoptic evaluation of lightwand-guided intubation has revealed a possibility of laryngeal interference and epiglottic distortion. Jaw lift, tongue traction or a combination of both have been used to assist in lightwand-guided intubation. This study fibreoptically evaluates lightwand-guided intubation using jaw lift and combined jaw and tongue traction. Eighty four patients with normal airway undergoing general anaesthesia were studied. This randomised, double blinded, cross over study was done in two phases. First phase - after achieving adequate depth of anaesthesia, a fibrescope was advanced nasally, and lightwand-guided intubation was carried out under direct fibreoptic visualisation with the aid of either jaw lift or combined jaw and tongue traction. Second phase - Extubation followed by reintubation using the other manoeuvre. Interference with laryngeal structures during intubation and position of the epiglottis at the end of intubation were noted. Epiglottic distortion (deviated to one side/infolded into trachea) was observed in 6 patients with jaw lift and 17 patients with combined jaw and tongue traction (P=0.003). Laryngeal interference was significantly higher (P=0.012) with combined manoeuvre (30/78) than with jaw lift alone (9/81). Although lightwand-guided intubation can be performed quickly and easily, interference with laryngeal structures and distortion of the epiglottis can occur. Jaw lift manoeuvre causes less laryngeal interference than combined jaw and tongue traction applied by a single operator.

Pulmonary tuberculosis (TB) is the most important form of the disease, although infection may also occur by way of the intestinal tract, tonsils and skin. Oral lesions consist of persistent ulcers or granulomatous masses. A 50 year old man had been diagnosed “necrotising granulomatous inflammation” following a biopsy of a lesion on lower lip, 21 months before at a medical centre. A chest-X-ray had not been performed and he had not been given any advise in respect of treatment. He was admitted to the hospital with cough, sputum, weakness, weight loss and lesions on his lower lip. In radiology, it was detected that he had supraclavicular, submental, cervical, mediastinal lymphadenopathies, pulmonary infiltrations with cavities, thickening and roughness on left oropharengial tonsil, thickenning on inner parts of larynx and bilateral surrenal thickening. The biopsy of lesions on larynx, tonsil and epiglottis revealed “necrotising granulomatous inflammation” and histopathology supported TB infection. Sputum acid-fast bacilli was positive and culture was positive for Mycobacterium tuberculosis complex. Two months of combination treatment resulted in a gradual relief of the symptoms, radiological response, disappearing of neck swelling and healing of lesions on lip, tonsil and larynx. Although unusual oral cavity manifestations of TB are rare, clinicians should be aware of possible occurrance.

Pyogenic granulomas are benign vascular neoplasms that most often arise from the skin and mucous membranes. The larynx is an unusual site for a pyogenic granuloma. A 60-year-old man presented with hoarseness. He had hypertension; otherwise his medical history was unremarkable. Indirect laryngoscopy revealed a nodular lesion on the epiglottis, and this finding was confirmed with computed tomography of the larynx. Surgical excision was performed via direct laryngoscopy, and the histopathological diagnosis was reported as pyogenic granuloma. The report discusses this lesion and the rare location in this case.

The pyogenic granuloma is a benign vascular lesion of the skin and mucous membranes that frequently seen in the head and neck. The etiology of this lesion remains unknown but trauma, gingival and periodontal diseases, bad oral hygiene, viral or fungal infections are considered in the etiology of pyogenic granuloma. The majority of pyogenic granulomas are located in the cheek and oral cavity but larynx localization is too rare. In this paper clinical findings of a 56- year-old-male patient with pyogenic granuloma of epiglottis was presented, differential diagnosis and treatment was discussed.

Hypoplasia of the epiglottis is a rare congenital anomaly. It is often associated with complex malformations and presents at birth and infancy with respiratory or feeding difficulties. The long-term evolution of hypoplastic epiglottis cases is not known. We report the case of a neonate with hypoplastic epiglottis who posed to be a diagnostic dilemma for neonatologists

Computed Tomograpy (CT) scan and Magnetic Resonance Imaging (MRI) evaluation of the larynx and hypopharynx can be tricky for the untrained eye. We discuss a peculiar pattern of the supraglottic airway at the level of the base of the epiglottis seen on axial CT and MR images, resembling a “black hat” or a “black sombrero.” The level of the base of the epiglottis also corresponds to that of the hyoid bone, where two valuable hypopharyngeal sub-sites are visible- the pyriform sinuses and the posterior hypophayngeal wall. A hat has basically two parts, an apical convex crown and a basal horizontal brim. (Figure 1.A) Correlating the hat’s appearance on axial CT and MR imaging, the hat appears black due to the presence of air at the supraglottic level wherein the crown is positioned anteriorly and the brim positioned posteriorly. (Figure 1.B) The top-most convex part of the crown corresponds to the base of the epiglottis. Anterior to it is the pre-epiglottic fat plane and the body of the hyoid bone. The crown is also flanked by the paraglottic fat plane on both sides that appears hypodense (dark) on CT and hyperintense (bright) on T1 MRI. On the other hand, the posterior-most portion of the hat’s brim abuts the posterior hypopharyngeal wall - laterally outlining the pyriform sinuses on each side. The area where the crown joins the brim corresponds to the aryepiglotic folds that are delineated laterally by the medial walls of the pyriform sinuses while its medial aspects correspond to portions of the supraglottis. (Figure 2) The size and configuration of the hat varies and can range from one with a big crown and a small brim (resembling a “bowler” or “derby hat”) to one with a tall crown and a floppy brim (resembling a “Mexican sombrero”). (Figures 2, 3) Infiltrating tumors and inflammatory processes can distort the hat’s usual symmetric configuration, and can be useful in determining possible sites of inflammation or infection, tumor origin, and spread to hypopharyngeal and supraglottic structures, as the hat’s center represents a potential space at the supraglottic area devoid of any soft tissue structures. (Figure 4) In radiology, “the bowler hat sign” and “Mexican hat sign” have been used to describe gastrointestinal polyps.1,2,3 The former “is produced by the acute angle of attachment of the polyp to the mucosa” while the latter “consists of two concentric rings and is produced by visualizing a pedunculated polyp head-on.”1 The “Mexican hat sign” has also been used to describe osmotic demyelination on MRI.4 To our knowledge, these terms have not been applied to the interpretation of supraglottic and hypopharyngeal CT and MRI axial images. Recognition of the “Black Sombrero” pattern can be helpful in understanding the anatomic relationship of the supraglottic and hypopharynx structures on axial CT and MR imaging, particularly in the evaluation of supraglottic and hypopharyngeal tumor spread.

Lymphangiomas are congenital lesions of the lymphatic system which are most commonly found in the head and neck, with over 90 % of lesions manifesting in children who are less than 2 years of age. Haemolymphangiomas are rare variant of lymphangioma, with the presence of red blood cells within the lymphatic channels. Laryngeal sites are usually in continuity with foci of disease in the neck. In general, symptoms are non–specific and they vary with the site and size of the mass. Usually, they occur before 2 years of age. Isolated cases of lymphangiomas with involvement of epiglottis are rare and only a few cases have been reported so far. We are reporting the case of a sixyear-old girl who presented with a mass in the epiglottis.