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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.

The article responds to feedback on the clinical performance of the LMA Blockbuster® in pediatric anesthesia, highlighting the importance of preventing epiglottic downfolding during insertion. The study focused on evaluating the positioning of the LMA Blockbuster® at the glottic level and did not specifically assess the ease of inserting an orogastric tube. Intracuff pressure was maintained at 60 cm H2O, and intubation was considered if three insertion attempts failed. The authors used 2% lignocaine jelly on the cuff, which has been shown to reduce postoperative sore throat without increasing aspiration risk. [Extracted from the article]

The article "Comment On 'Comparative analysis of LMA Blockbuster® clinical performance: Blind versus Miller laryngoscope-guided insertion in paediatric general anaesthesia – A double-blinded, randomised controlled trial'" published in the Indian Journal of Anaesthesia discusses concerns regarding the evaluation of laryngeal mask airway (LMA) malposition in pediatric patients. The authors highlight the importance of assessing vertical and rotational malposition of the LMA, as well as the need to consider the second seal between the distal cuff and the esophagus. They also suggest lower intracuff pressures and caution against the use of 2% lignocaine jelly in pediatric patients. The article concludes with a statement of no financial support or conflicts of interest. [Extracted from the article]

This article, titled "How to Breathe," explores the author's personal experiences and reflections on the theme of breathing. The author discusses various moments in their life where breathing has played a significant role, such as encounters with a former partner, childhood experiences, the loss of their child, and their connection to nature. The author also touches on the importance of breathing for their own survival and the impact it has had on their perspective. The article is written by Court Harler, a queer freelance writer, editor, and educator based in Las Vegas, Nevada. [Extracted from the article]

Pemphigus is a rare autoimmune mucocutaneous bullous disease that can be life-threatening. We report a case of pemphigus vulgaris with pharyngeal ulcer as the initial presentation that was treated with glucocorticoid therapy. [ABSTRACT FROM AUTHOR]

To evaluate swallowing in patients who underwent CO2 LASER Partial Epiglottectomy (CO2-LPE) for Obstructive Sleep Apnea Syndrome and to assess the risk of aspiration with this technique. Chart review of adult patients who underwent CO2-LPE between 2016 and 2020, in a secondary care hospital. Patients underwent surgery for OSAS, in accordance to Drug Induced Sleep Endoscopy findings and an objective swallowing evaluation was done at least 6 months after surgery. Eating Assessment Tool (EAT-10) questionnaire was applied and Volume-Viscosity Swallow Test (V-VST) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) were performed. Dysphagia was classified according to Dysphagia Outcome Severity Scale (DOSS). Eight patients were included in the study. The mean time between surgery and the swallowing evaluation was 50 (±13,2) months. Only 3 patients presented ≥ 3 points on EAT-10 questionnaire. Two patients presented signs of decreased efficacy of swallowing (piecemeal deglutition) but none had a decrease in safety, according to V-VST. Although 50% of the patients presented some pharyngeal residue on FEES, it was classified as trace to mild in most of the cases. No evidence of penetration or aspiration was identified (DOSS ≥ 6 in all patients). The CO2-LPE is a potential treatment for OSAS patients with epiglottic collapse and no evidence of swallowing safety compromise was found. [ABSTRACT FROM AUTHOR]

Objectives: This manuscript aims to present a novel and successful intervention for intractable aspiration following a supracricoid laryngectomy (SCL) that may avoid the need for total laryngectomy in patients experiencing intractable aspiration after SCL. Study design: This report describes a novel approach to treat intractable aspiration and feeding tube-dependency due to an incomplete posterior apposition of the laryngeal surface of the epiglottis to the arytenoids after a SCL in a 67-year-old man. Methods: The right and left aryepiglottic folds and the median glossoepiglottic fold were denuded using a CO2 laser. Then, an arytenoepiglottopexy was completed by placing 4-0 Vicryl between the lateral aspect of the epiglottis and arytenoids; thus, approximating these structures. Results: Two weeks after surgery, fiberoptic endoscopic evaluation of swallowing demonstrated improved closure of the larynx upon swallowing with great upgrading in the Penetration-Aspiration scale (PAS). PAS improved from a 6 to 2, corresponding to, transient penetration for moderately thick liquids and puree solids. He also demonstrated improved secretion management and airway protection. Following a 4-week course of intensive dysphagia therapy, a modified barium swallow revealed a significant improvement in airway protection, with a PAS score of 1 (no airway invasion). Conclusions: Chronic aspiration is a life-threatening condition that can severely reduce patients' quality of life. Despite the use of current therapeutic approaches, a subset of patients will remain plagued by persistent symptoms. We introduce an innovative, simple, and quick endoscopic technique that offers benefit in controlling aspiration after SCL. Level of Evidence: NA [ABSTRACT FROM AUTHOR]

Objectives: Studies have shown that some ultrasonic indicators can predict difficult airways in adults to an extent. However, whether ultrasonic parameters can be used to predict difficult airways in children is unclear. This study investigated the predictive value of several ultrasonic indices for difficult laryngoscopy (DL) in children. Methods: Pediatric patients aged 5 to 12 years who underwent endotracheal intubation under general anesthesia were enrolled. The hyomental distance in the extended position (HMDE), tongue thickness, midsagittal tongue cross-sectional area, tongue width, and distance from skin to epiglottis (DSE) were measured by ultrasound before anesthesia. The study end point was DL. The receiver operating characteristic curve was used to evaluate the predictive value of each parameter. Results: Three hundred and ten children were included in the final analysis, and fifteen (4.8%) children had DL. The shortened HMDE assessed by ultrasound could help identify children aged 5 to 12 years with DL (5–8 years: area under the curve (AUC) 0.74, sensitivity 0.88, specificity 0.60; 9–12 years: AUC 0.72, sensitivity 0.71, specificity 0.83). An increased DSE could help identify children aged 5 to 8 years with DL (AUC 0.76, sensitivity 0.88, specificity 0.69). Conclusions: Ultrasonic measurement of the HMDE can be used to predict DL in children aged 5 to 12 years. The DSE measured by ultrasound can be used to predict DL in children aged 5 to 8 years. Clinical relevance statement: The hyomental distance and the distance from skin to epiglottis measured by ultrasound can be used to predict difficult laryngoscopy in children, which can help reduce serious complications caused by unanticipated difficult airways in children during anesthesia. Key Points: • Ultrasonic measurement of the hyomental distance in the extended position may be an effective predictor of difficult laryngoscopy in children aged 5 to 12 years. • The distance from skin to epiglottis measured by ultrasound can be used to predict difficult laryngoscopy in children aged 5 to 8 years. • Preoperative airway assessment using ultrasound can be effectively applied in children and has a great application prospect. [ABSTRACT FROM AUTHOR]

Background: Severe laryngomalacia, characterized by apnea, hypoxia, and feeding difficulties, is an uncommon diagnosis that often requires surgical intervention with supraglottoplasty. Children who require surgery at a young age and those with additional comorbidities pose a special challenge and may require further surgical interventions. Posterior displacement of the epiglottis has been noted in some infants with congenital stridor and is commonly treated with epiglottopexy. The goal of our study is to review the outcomes of epiglottopexy combined with supraglottoplasty in our cohort of infants younger than 6 months old with severe laryngomalacia. Methods: A retrospective chart review of infants younger than 6 months old who underwent epiglottopexy combined with supraglottoplasty for severe laryngomalacia from January 2018 to July 2021 at a tertiary care children's hospital. Results: 13 patients (age 1.3 week-5.2 months) underwent supraglottoplasty and epiglottopexy for severe laryngomalacia and epiglottis retroflection. The patients were admitted to the intensive care unit and remained intubated for at least one night. All patients demonstrated subjective and objective improvement in upper airway respiratory signs and symptoms. Ten patients demonstrated aspiration immediately postoperatively, despite 4 of them having no concern for aspiration at preoperative evaluation. On follow-up, 1 patient required revision supraglottoplasty and epiglottopexy for persistent laryngomalacia, and 2 patients required tracheostomy tube placement due to cardiopulmonary comorbidities. Conclusion: Infants younger than 6 months old with medical comorbidities undergoing epiglottopexy with supraglottoplasty may demonstrate significant improvement in respiratory symptoms. Worsening dysphagia may complicate the postoperative period, particularly among children with medical comorbidities. [ABSTRACT FROM AUTHOR]

Objective: To characterize the prevalence and presentation of laryngomalacia and efficacy of supraglottoplasty (SGP) in a cohort of patients with Pierre Robin Sequence (PRS). Design: Retrospective cohort study. Setting: Tertiary-care children's hospital. Patients, Participants: Consecutive patients with PRS born between January 2010 and June 2018. Main Outcome Measures: Chart review included demographics, comorbid airway obstruction including laryngomalacia, timing of surgical interventions, clinical symptoms, sleep study data, and modified barium swallow study data. Results : 126 patients with PRS were included; 54% had an associated syndrome, 64% had an overt cleft palate, and 22% had a submucous cleft palate. 64/126 were noted to have laryngomalacia (51%). Patients with concurrent PRS and laryngomalacia were significantly more likely to have submucous cleft palate (P =.005) and present with aspiration with cough (P =.01) compared to patients with PRS without laryngomalacia. Patients with concurrent laryngomalacia and PRS showed a significant decrease in apnea–hypopnea index (AHI) and obstructive AHI (OAHI) after mandibular distraction, with a median AHI and OAHI improvement of 22.3 (P =.001) and 19.8 (P =.002), respectively. Patients who underwent only SGP did not show significant improvement in these parameters (P =.112 for AHI, P =.064 for OAHI). Conclusions : The prevalence of laryngomalacia in our PRS cohort was 51%. Patients with PRS and laryngomalacia are more likely to present with overt aspiration compared to patients with PRS without laryngomalacia. These data support that laryngomalacia does not appear to be a contraindication to pursuing MDO. [ABSTRACT FROM AUTHOR]

Introduction: There is an increasing interest in using airway ultrasound to predict difficult intubation. Studies to date have excluded pregnant women in reporting airway measurements. We performed this study to compare the mean distance from skin to epiglottis in parturients to that reported in previously published studies. We also assessed the correlation of mean distance from skin to epiglottis with other elements of the airway examination. Methods: A total of 100 parturients were recruited from a tertiary hospital's labor and delivery floor. Standard physical examination parameters were recorded in addition to the mean distance from skin to epiglottis for all subjects. The ratio of height-to-thyromental distance was used to classify airways as potentially favorable or unfavorable. Results: The average mean distance from skin to epiglottis in parturients was 19.9 ± 3.3 mm and followed a normal distribution. The mean distance from skin to epiglottis was moderately correlated with height and body mass index. There was no difference in mean distance from skin to epiglottis between subjects with favorable versus unfavorable airways as classified by ratio of height-to-thyromental distance. Conclusion: The typical mean distance from skin to epiglottis in parturients falls between previously published values in mixed populations. Previously published cut-off values using airway ultrasound to predict difficult intubation are not likely to apply to parturients. [ABSTRACT FROM AUTHOR]

Purpose: Galen's anastomosis, which is placed over the dorsal surface of the posterior cricoarytenoid muscle, is formed by the internal branch of the superior laryngeal nerve and the dorsal branch of the recurrent laryngeal nerve (RLN). This study aims to contribute literature about the prevalence of Galen's anastomosis which is still a controversial issue and indicates the prevalence of this type of anastomosis in both sides of the larynx and indicate the importance of this anastomosis in different neck surgeries and procedures. Subjects and Methods: Twenty-two adult formalin-fixed hemilaryngeal (11 larynx) specimens' anatomical micro-dissection were performed on both sides (right-left) posteriorly. Every specimen consisted of larynx, trachea, epiglottis, and hyoid bone. Internal laryngeal nerve, recurrent laryngeal nerve, and inferior thyroid artery were freed up connective tissue to better analyze their relationship and to find their exact course with termination point. Results: In our current study, total Galen's anastomosis prevalence was found %54.53 with %27.27 right single trunk, %18.18 left single trunk, 4.54 left plexus formation, and 4.54 left double trunk. There has not been any anastomotic structure in %22.72 of the left side and in %22.72 of the right side microdissection of laryngeal specimens. Conclusion: During laryngeal or thyroid surgery, observation of an unknown intralaryngeal branching pattern may lead to confusion and may increase the risk of iatrogenic nerve injury, thus it is crucial to contribute to the literature about microanatomy and prevalence of Galen's anastomosis. [ABSTRACT FROM AUTHOR]

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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

Surgeons determine the treatment method for patients with epiglottis obstruction based on its severity, often by estimating the obstruction severity (using three obstruction degrees) from the examination of drug-induced sleep endoscopy images. However, the use of obstruction degrees is inadequate and fails to correspond to changes in respiratory airflow. Current artificial intelligence image technologies can effectively address this issue. To enhance the accuracy of epiglottis obstruction assessment and replace obstruction degrees with obstruction ratios, this study developed a computer vision system with a deep learning-based method for calculating epiglottis obstruction ratios. The system employs a convolutional neural network, the YOLOv4 model, for epiglottis cartilage localization, a color quantization method to transform pixels into regions, and a region puzzle algorithm to calculate the range of a patient's epiglottis airway. This information is then utilized to compute the obstruction ratio of the patient's epiglottis site. Additionally, this system integrates web-based and PC-based programming technologies to realize its functionalities. Through experimental validation, this system was found to autonomously calculate obstruction ratios with a precision of 0.1% (ranging from 0% to 100%). It presents epiglottis obstruction levels as continuous data, providing crucial diagnostic insight for surgeons to assess the severity of epiglottis obstruction in patients. [ABSTRACT FROM AUTHOR]

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). [ABSTRACT FROM AUTHOR]

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

This report presents an unusual case of epiglottic downfolding through the vocal cords which occurred during direct laryngoscopy and loss of view with intubation. Few indicators of an issue were present postintubation, but the providers' interest in one peculiar detail led to timely discovery of the issue avoiding any further injury or complications to the patient. [ABSTRACT FROM AUTHOR]

Objective: Partial epiglottidectomy has a role in improving dysphagia due to epiglottic obstruction. This study evaluates objective parameters of swallow function in patients who underwent partial epiglottidectomy. Study Design: Retrospective study design. Setting: Tertiary Care University Academic Medical Center. Methods: A review was performed of patients who underwent CO2 laser partial epiglottidectomy for the treatment of dysphagia at a single tertiary care academic center over a 4‐year period. Objective swallowing parameters were evaluated from pre‐ and postoperative modified barium swallow studies using SwallowTail Advanced Measurement software using blinded reviewers. The postswallow pharyngeal residue (bolus clearance ratio or BCR), spatiotemporal swallowing variables (oropharyngeal [OPT], hypopharyngeal [HPT], and total pharyngeal transit times [TPT]), and airway protection (Penetration‐Aspiration Scale [PAS]) were analyzed. Student paired t test was used to determine significant changes in outcome parameters pre‐ and postsurgery. Results: Forty‐three patients (age range 45‐92 years, median 70) met the inclusion criteria. A majority (69.8%) had a history of external beam radiation therapy for head and neck cancer. BCR decreased significantly from a mean of 31.7% presurgery to 24.2% (p =.01) postsurgery. OPT, HPT, and TPT did not differ significantly postsurgery. The mean Eating Assessment Tool‐10 score improved from 25.1 to 20.2 after treatment (p =.03). PAS score improved by 15.4% and remained stable at 66.2% after surgery. Conclusion: Partial epiglottidectomy improves pharyngeal bolus clearance in properly selected patients with dysphagia due to epiglottic obstruction. Patients demonstrated stable swallow function with the benefit of reduced postswallow residue following surgical intervention. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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 FROM AUTHOR]

Purpose: The aim of this study was to establish preliminary reference values for the Visual Analysis of Swallowing Efficiency and Safety (VASES)—a standard- ized rating methodology used to evaluate swallowing safety and efficiency for flexible endoscopic evaluation of swallowing (FEES). Method: FEES were completed in nondysphagic, community-dwelling adults using a standardized protocol of 15 swallowing trials that varied by bolus size, consistency, contrast agent, and swallowing instructions. FEES were blindly analyzed using VASES. Primary outcome measures included bolus location at swallow onset, Penetration–Aspiration Scale (PAS) scores, and percentage- based residue ratings for six anatomic landmarks. Secondary outcome mea- sures included sip size, bite size, and number of swallows. Results: Thirty-nine healthy adults completed the study, yielding an analysis of 584 swallows. Swallows were initiated with the bolus in the pharynx for 41.8% of trials. PAS 1 was the most common score, accounting for 75.3% of trials, followed by PAS 3, which accounted for 18.8% of trials. When residue was present (> 0%), the amount was relatively small across all anatomic landmarks, with median residue ratings of 2.0% (oropharynx), 1.5% (hypopharynx), 3.0% (epiglottis), 3.0% (laryngeal vestibule), and 3.5% (vocal folds). Five events of aspiration were observed, which were characterized by subglottic residue rat- ings of 1%, 3%, 10%, 24%, and 90%. The average sip size of self-selected volume cup sips of water was 19.8 ml, and the average bite size of a 3.0-g sal- tine cracker was 1.33 g. Moreover, 78% of the trials in this study protocol (except 90-ml trials) were completed in a single swallow. Discussion: The results from this study provide preliminary norms for VASES that could be used as a reference when assessing functional swallowing out- comes during FEES. While this is an important first step in establishing norms for FEES and VASES, clinicians and researchers should be mindful that the normative reference values from this study are from a relatively small study sample (N = 39), with most people below the age of 60 years (n = 30). Future research should expand on these norms by including a greater number of people across the age continuum and with greater racial, ethnic, and gender diversity. [ABSTRACT FROM AUTHOR]

Basaloid squamous cell carcinoma (BSCC) is an uncommon and severe variant of squamous cell carcinoma (SCC). The tumor arises most commonly in the region of the head-and-neck. It is normally seen in the epiglottis, pyriform fossa, and the base of the tongue. It also occurs less frequently in areas like the palate, buccal mucosa, gingiva and the floor of mouth. Once compared to SCC, BSCC is documented for its aggressiveness in the head-and-neck area, along with its recurrence in local and cervical lymph nodes for its distant metastasis to the lungs. In addition, local lymph nodes are more common in regular recurrence rates. BSCC in the head and neck is more likely to spread to other parts of the body. It has an increased tendency to metastasize when compared with other tumors. We report a rare case of a BSCC arising in the buccal mucosa in a 65-year-old male patient and explain its clinicopathologic characteristics. [ABSTRACT FROM AUTHOR]

Study objectivesTo determine whether there is a consistent epiglottic pressure value that predicts respiratory arousal from sleep.MethodsThirty-one patients with obstructive sleep apnea underwent overnight polysomnography while instrumented with an epiglottic catheter to measure airway pressures. Nadir epiglottic pressures during respiration events (obstructive apneas/hypopneas) terminated with or without arousals were compared. The events were selected by two methods, (1) 20 events with/without arousals were randomly selected, and (2) Events were sampled in pairs (one terminated with arousal and one without arousal) to minimize the effect of sleep duration/stage on the measurement.ResultsA total of 1,317 respiratory events were analyzed. There was substantial variability in nadir epiglottic pressure within an individual and among different individuals. The average pressure of 20 randomly selected events with arousals was (-21.2 ± 11.2, ranged -6.68 to -63.34 cm H2O). The nadir epiglottic pressure during respiratory events in NREM stage 2 sleep terminated with arousals was more negative compared with those terminated without arousals using both sampling methods (-23.5 vs. -18.5 cm H2O, p = 0.007 and -20.3 vs. -16.3 cm H2O, p < 0.001).ConclusionsThere were very different levels of epiglottic pressures that preceded arousals within and among individuals. However, cortical arousals are associated with a level of more negative epiglottic pressure compared to events terminated without arousal, findings which support the concept of a respiratory arousal threshold.Clinical trial registrationThe study used existing data to study methodology (from clinical trial "The Impact of Arousal Threshold in Obstructive Sleep Apnea" https://clinicaltrials.gov/show/NCT02264353) and it is not a clinical trial.

The article in Anaesthesia discusses the implementation of a universal paediatric videolaryngoscopy program, which showed a reduction in glottic view restrictions compared to direct laryngoscopy. The study highlights the importance of anatomical, functional, and technical factors in classifying videolaryngoscopic tracheal intubation in children. It also emphasizes the need for a clear definition of 'first-attempt success' to improve the comparability of studies. [Extracted from the article]

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 FROM AUTHOR]

Basaloid squamous cell carcinoma (BSCC) is a rare, distinctive, and aggressive variant of squamous cell carcinoma (SCC) primarily seen in the upper aerodigestive tract with epiglottis, soft palate, and base of the tongue being site of high preference in head and neck region. It differs from conventional SCC histologically and immunologically, is most frequently found in males in their sixth and seventh decades, and is frequently linked to alcohol and tobacco use. High stage disease with distant metastases, a high recurrence rate, and a dismal prognosis is how BSCC typically manifests. In the present article, we report four cases of BSCC. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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Supraglottic thermal burns resulting from ingestion of excessively hot food or drink can potentially lead to fatal airway obstruction due to severe edema. In this case we evaluate an adult male who presented to the emergency department (ED) with sore throat and mild voice hoarseness that began while eating hot rice soup two days prior. The patient states that after taking a bite of the hot soup, he coughed due to the heat. Shortly after, he felt a burning sensation in his throat and developed a foreign body sensation. A visual examination with video laryngoscopy of the upper airway showed no evidence of foreign bodies; however, there were suspected thermal burns near the patient's epiglottis. This case demonstrates how thermal burns can be evaluated and treated with conservative measures to reduce edema, but care takers should be aware of the severe burns leading to complete airway obstruction. Topics: Supraglottic burns, airway obstruction, laryngoscopy. [ABSTRACT FROM AUTHOR]

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.

Neuroendocrine carcinomas are a spectrum of rare and highly heterogeneous malignant tumors. Neuroendocrine carcinomas mainly arise from neuroendocrine cells scattered throughout the body. They mainly occur in the lung and gastrointestinal tract. Atypical carcinoid of the larynx is a rare type of neuroendocrine carcinoma, which is easily misdiagnosed as hemangioma in appearance. We mainly feature the disease to you through the diagnosis and treatment of a case of atypical carcinoid of the larynx. [ABSTRACT FROM AUTHOR]

Background: Antrochoanal polyp (ACP), also known as Killian polyp, is a benign lesion of maxillary sinus origin with infective etiology. ACPs most often present with nasal obstruction and rhinorrhea, but may rarely prolapse causing acute respiratory distress. We herein report a rare case of ACP-causing stridor. Case description: Large ACPs may extend into the nasopharynx and reach almost up to the epiglottis. A 19-year-old girl presented with nasal obstruction, dysphagia, and stridor. She was diagnosed with left ACP reaching the suprahyoid epiglottis. The patient underwent functional endoscopic sinus surgery (FESS). The postoperative period was uneventful. Conclusion: Though the ACP is a common lesion, it has various presentations and may extend into the hypopharynx. ACP is managed surgically with complete excision to reduce the risk for recurrence and with less morbidity. Clinical significance: It is important to keep in mind that ACP when untreated can lead to stridor. [ABSTRACT FROM AUTHOR]

Characterization of the oropharynx, a subdivision of the pharynx between the soft palate and the epiglottis, is limited to simple measurements. Structural changes in the oropharynx in whiplash‐associated disorder (WAD) cohorts have been quantified using two‐dimensional (2D) and three‐dimensional (3D) measures but the results are inconsistent. Statistical shape modelling (SSM) may be a more useful tool for systematically comparing morphometric features between cohorts. This technique has been used to quantify the variability in boney and soft tissue structures, but has not been used to examine a hollow cavity such as the oropharynx. The primary aim of this project was to examine the utility of SSM for comparing the oropharynx between WAD cohorts and control; and WAD severity cohorts. The secondary aim was to determine whether shape is associated with sex, height, weight and neck length. Magnetic resonance (MR) T1‐weighted images were obtained from healthy control (n = 20), acute WAD (n = 14) and chronic WAD (n = 14) participants aged 18–39 years. Demographic, WAD severity (neck disability index) and body morphometry data were collected from each participant. Manual segmentation of the oropharynx was undertaken by blinded researchers between the top of the soft palate and tip of the epiglottis. Digital 3D oropharynx models were constructed from the segmented images and principal component (PC) analysis was performed with the PC weights normalized to z‐scores for consistency. Statistical analyses were undertaken using multivariate linear models. In the first statistical model the independent variable was group (acute WAD, chronic WAD, control); and in the second model the independent variable was WAD severity (recovered/mild, moderate/severe). The covariates for both models included height, weight, average neck length and sex. Shape models were constructed to visualize the effect of perturbing these covariates for each relevant mode. The shape model revealed five modes which explained 90% of the variance: mode 1 explained 59% of the variance and primarily described differences in isometric size of the oropharynx, including elongation; mode 2 (13%) primarily described lateral (width) and AP (depth) dimensions; mode 3 (8%) described retroglossal AP dimension; mode 4 (6%) described lateral dimensions at the retropalatal‐retroglossal junction and mode 5 (4%) described the lateral dimension at the inferior retroglossal region. There was no difference in shape (mode 1 p = 0.52; mode 2 p = 0.96; mode 3 p = 0.07; mode 4 p = 0.54; mode 5 p = 0.74) between control, acute WAD and chronic WAD groups. There were no statistical differences for any mode (mode 1 p = 0.12; mode 2 p = 0.29; mode 3 p = 0.56; mode 4 p = 0.99; mode 5 p = 0.96) between recovered/mild and moderate/severe WAD. Sex was not significant in any of the models but for mode 1 there was a significant association with height (p = 0.007), mode 2 neck length (p = 0.044) and in mode 3 weight (p = 0.027). Although SSM did not detect differences between WAD cohorts, it did detect associations with body morphology indicating that it may be a useful tool for examining differences in the oropharynx. [ABSTRACT FROM AUTHOR]

Femoral facial syndrome (FFS) is a rare condition which may present with hypoplasia or aplasia of the femora and unusual facies characterized by long philtrum, thin upper lip and micrognathia. We present the case of a ten-month old infant with FFS who had retroglossal obstruction and who was treated with a pre-epiglottic baton plate. The pre-epiglottic baton plate can be a simple, non-invasive and effective tool for the clinical management of syndromic patients with mild-to-moderate upper airway obstruction due to micrognathia. [ABSTRACT FROM AUTHOR]

Alternative materials for postmortem diagnosis in the case of fatal poisonings are much needed when standard materials, such as blood and urine, are unavailable. The study presents a case of fatal mass methanol intoxication resulting from industrial alcohol consumption. The study aimed to determine methanol and formic acid concentrations in epiglottis cartilage, costal cartilage, and intervertebral disc cartilage and to analyze the correlation between their concentrations in cartilage tissues and the femoral blood. Methanol and formic acid concentrations in samples collected from 17 individuals (n = 17) were estimated using gas chromatography with flame ionization detection (GC-FID). Methanol concentration in the costal cartilage correlated with its concentration in the femoral blood (r = 0.871). Similar correlations were found for epiglottis cartilage (r = 0.822) and intervertebral disc cartilage (r = 0.892). Formic acid concentration in the blood correlated only with its concentration in urine (r = 0.784) and the epiglottis (r = 0.538). Cartilage tissue could serve as an alternative material for methanol analyses in postmortem studies. Formic acid, a methanol metabolite, does not meet the requirements for its presence determination in cartilage tissues. [ABSTRACT FROM AUTHOR]

Alveolar soft part sarcoma (ASPS) is an aggressive soft-tissue malignancy, notorious for its metastasis to other tissues. A considerable number of cases in the head and neck have been reported but not in the hypopharynx. We describe a 31-year-old man with an incidental finding of a hypopharyngeal mass. Flexible laryngoscopy revealed a fleshy mass 2 × 2 cm2 originating from the left hypopharynx and overlying the epiglottis. Computed tomography scan demonstrated a soft tissue mass in the left wall of the oropharynx measuring about 2.2 × 1.8 cm2, projecting into the hypopharyngeal air space. Magnetic resonance imaging showed a significant thickening of the left hypopharyngeal wall forming a mass lesion occupying the left pyriform sinus and abutting the left aryepiglottic fold. Histopathology indicated that tumor cells were polygonal and epithelioid, with abundant eosinophilic to clear flocculent cytoplasm, eccentric nuclei, and prominent nucleoli. The tumor was positive for smooth muscle actin with rare cells staining for Human Melanoma Black (HMB45). Fluorescence in situ hybridization for transcription factor E3 was also performed and supported the above diagnosis. Our study reports the first case of ASPS in the hypopharynx. [ABSTRACT FROM AUTHOR]

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.

This article, published in the journal Ultrasound in Obstetrics & Gynecology, discusses a study that aimed to obtain fetal upper esophagus biometry and identify a second trimester marker for esophageal atresia (AE). The study enrolled single physiological pregnancies between 19 and 23 weeks and performed 2D and 3D ultrasound evaluations of the upper esophagus. The results showed that a thickening in a specific area of the esophagus, referred to as "P2," correlated with a subsequent esophageal pouch (EP) and AE. However, further studies are needed to confirm these findings due to the rarity of the disease and the small sample size. [Extracted from the article]

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

Background: In morbidly obese patients, airway management is challenging since the incidence of difficult intubation is three times than those with a BMI within the healthy range. Standard preoperative airway evaluation may help to predict difficult laryngoscopy. Recent studies have used ultrasonography-measured distance from skin to epiglottis and pretracheal soft tissue at the level of vocal cords, and cut-off points of 27.5 mm and 28 mm respectively have been proposed to predict difficult laryngoscopy. The purpose of this study is to evaluate ultrasonography-measured distance from skin to epiglottis for predicting difficult laryngoscopy in morbidly obese Thai patients. Methods: This prospective observational study was approved by the Ethics Committee of the Faculty of Medicine, Prince of Songkla University. Data were collected from January 2018 to August 2020. Eighty-eight morbidly obese patients (BMI ≥ 35 kg/m2) requiring general anesthesia with endotracheal intubation for elective surgery were enrolled in the Songklanagarind Hospital. Preoperatively, anesthesiologists or nurse anesthetists who were not involved with intubation evaluated and recorded measurements (body mass index, neck circumference, inter incisor distance, sternomental distance, thyromental distance, modified Mallampati scoring, upper lip bite test, and distance from skin to epiglottis by ultrasound. The laryngoscopic view was graded on the Cormack and Lehane scale. Results: Mean BMI of the eighty-eight patients was 45.3 ± 7.6 kg/m2. The incidence of difficult laryngoscopy was 14.8%. Univariate analysis for difficult laryngoscopy indicated differences in thyromental distance, sternomental distance and the distance from skin to epiglottis by ultrasonography. The median (IQR) of thyromental distance in difficult laryngoscopy was 6.5 (6.3, 8.0) cm compared with 7.5(7.0, 8.0) cm in easy laryngoscopy (p-value 0.03). The median (IQR) of sternomental distance in difficult laryngoscopy was 16.8 (15.2, 18.0) cm compared with 16.0 (14.5, 16.0) cm in easy laryngoscopy (p-value 0.05). The mean distance from skin to epiglottis was 12.2 ± 3.3 mm Mean of distance from skin to epiglottis in difficult laryngoscopy was 12.5 ± 3.3 mm compared with 10.6 ± 2.9 mm in easy laryngoscopy (p-value 0.05). Multivariate logistic regression indicated the following factors associated with difficult laryngoscopy: age more than 43 years (A), thyromental distance more than 68 mm(B) and the distance from skin to epiglottis more than 13 mm(C). The scores to predict difficult laryngoscopy was calculated as 8A + 7B + 6C based on the data from our study. One point is given for A if age was more than 43 years old, 1 point is given for B if thyromental distance was less than 6.8 cm and 1 point is given for C if the distance from skin to epiglottis by ultrasonography was more than 13.0 cm. The maximum predicting score is 21, which indicates a probability of difficult laryngoscopy among our patients of 36.36%, odds 0.57, likelihood ratio 3.29 and area under the ROC curve of 0.77, indicative of a good predictive score. Conclusions: Age, thyromental distance and ultrasonography for the distance from skin to epiglottis can predict difficult laryngoscopy among obese Thai patients. The predictive score indicates the probability of difficult laryngoscopy. [ABSTRACT FROM AUTHOR]