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Data and Picture Interpretation Stations: Cases 1–45
Published in Peter Kullar, Joseph Manjaly, Livy Kenyon, Joseph Manjaly, Peter Kullar, Joseph Manjaly, Peter Kullar, ENT OSCEs, 2023
Peter Kullar, Joseph Manjaly, Livy Kenyon, Joseph Manjaly, Peter Kullar, Joseph Manjaly, Peter Kullar
Laryngomalacia is the most common cause of stridor in infants. It presents within the first few weeks of life and the symptoms peak at around 6 months old and usually resolves by the end of the second year of life. It is caused by the collapse of the supraglottic structures on inspiration and causes high-pitched inspiratory stridor which typically worsens when supine or while crying. There is often a history of intermittent choking with feeding and recurrent chest infections. Severe cases result in difficulty feeding and increased metabolic expenditure on work of breathing (demonstrating tracheal tug, sternal recession and intermittent cyanosis) so that they lose significant weight and drop off centiles on growth charts. Laryngoscopy shows shortened aryepiglottic folds, an omega-shaped retroflexed epiglottis with normal vocal cord mobility and dynamic collapse of the supraglottic structures on inspiration. Most cases can be managed non-surgically with modifying feeding behaviours, encouraging upright positioning while feeding, pacing feeding with frequent burping, modifying the texture of feeds with thickener and starting treatment for reflux to reduce any laryngeal oedema. If there are signs of failure to thrive, a supraglottoplasty may be performed to widen the laryngeal inlet and reduce work of breathing.
Congenital Laryngeal Disease
Published in Raymond W Clarke, Diseases of the Ear, Nose & Throat in Children, 2023
Mild cases need no intervention. There is an association with gastro-oesophageal reflux, but the precise relationship is unclear and the role of anti-reflux treatment is uncertain. More severe cases warrant referral to a paediatric ORL clinic where flexible endoscopy will demonstrate the dynamic features and help reassure the parents. Persistent cases, or where there is failure to thrive, diagnostic uncertainty or concern about associated conditions will need admission for rigid airway endoscopy. This is to confirm the diagnosis, exclude any other pathology and, if appropriate, improve the symptoms by surgery. The preferred technique for most paediatric otolaryngologists is an ‘aryepiglottoplasty’ (Figure 23.2). This involves division of the aryepiglottic folds to open the laryngeal introitus, sometimes combined with removal of excessive and redundant mucosa. Excessive tissue removal risks postoperative aspiration, and a conservative approach is preferred.
Upper airway bronchoscopic interpretation
Published in Don Hayes, Kara D. Meister, Pediatric Bronchoscopy for Clinicians, 2023
Anita Deshpande, Cherie A. Torres-Silva, Catherine K. Hart
Airway malacia, which includes laryngomalacia, tracheomalacia, and bronchomalacia, is a dynamic obstruction of the airways and is the most common congenital airway anomaly in children. Laryngomalacia is a condition in which supraglottic structures, including the aryepiglottic folds, the arytenoid, corniculate, or cuneiform cartilages, the epiglottis, or a combination of all the above, collapse into the larynx and obstruct airflow during inspiration (Video 4.1). Flexible bronchoscopy via a trans-nasal approach during spontaneous ventilation allows for thorough dynamic evaluation. Common findings include shortened aryepiglottic folds, an omega-shaped epiglottis, and redundant arytenoid mucosa that can prolapse into the larynx.17
Airflow through the supraglottis during inspiration
Published in Computer Methods in Biomechanics and Biomedical Engineering, 2023
L. Reid, M. Hayatdavoodi, S. Majumdar
The presentation of EILO typically occurs in the supraglottic region, but closure at the glottis, or a combination of both has been documented (Nielsen et al. 2013; Walsted et al. 2021). Supraglottic collapse during EILO involves the anteromedial movement of the arytenoid cartilages and overlying mucosa with their associated corniculate cartilages, including the posterior aspect of the aryepiglottic folds. The supraglottis is defined as the upper region of the larynx situated between the laryngeal inlet and the glottis. The mechanism behind supraglottic collapse is largely unknown but several hypotheses have been proposed. Halvorsen et al. (2017) published a statement on behalf of the European Respiratory Society and European Laryngological Society which outlines three pathophysiological mechanisms of inducible laryngeal obstruction, with mechanical insufficiency being implicated in the supraglottic obstruction observed during exercise. This hypothesis suggests that laryngeal tissue is unable to withstand forces induced by inspiratory airflow.
The continuous laryngoscopy exercise test in severe or in difficult-to-treat asthma in adults: a systematic review
Published in Journal of Asthma, 2023
Tuuli Thomander,, L. Pekka Malmberg,, Sanna Toppila-Salmi,, Leena-Maija Aaltonen,, Paula Kauppi,
EILO was estimated by visual scoring in all the studies (1,5–9). Most of the studies adopted the Norwegian standardized scoring system for estimating the level of laryngeal obstruction and placed patients with moderate to severe grade in the EILO group (1,5–9). Mild laryngeal obstruction was not diagnostic for EILO. In the study of Tervonen et al. diagnosis of EILO was based on findings of inspiratory stridor, supraglottic collapse of arytenoids and aryepiglottic folds toward the aditus of the larynx, and vocal cord adduction (8). In two manuscripts, moderate-to-severe EILO were grouped together (5,8). Additionally, in two other studies the number of study individuals suffering from glottic or supraglottic obstruction or both was not clearly expressed for each subgroup (6,7). It was not possible to estimate how many study individuals experienced either severe glottic or supraglottic obstruction, as these often coexist and the same subjects may be included in both subgroups.
Gold laser removal of a large ductal cyst on the laryngeal surface of the epiglottis
Published in Baylor University Medical Center Proceedings, 2021
Brooke Jensen, Evan Nix, Pranati Pillutla, Joehassin Cordero
A 55-year-old man was referred to the clinic after a difficult intubation during an implantable cardioverter-defibrillator placement surgery, where a mass was reportedly blocking the view to the glottis. The patient described a prior “clothesline injury” that occurred at age 9 with no associated stridor or difficulty breathing. Postinjury, he experienced a peculiar and muffled dysphonia with no signs of dyspnea or dysphagia. A computed tomography scan confirmed the presence of a large mucocele in the supraglottic region (Figure 1). Flexible laryngoscopy revealed a mass originating at the right laryngeal edge of the epiglottis extending to the right aryepiglottic fold (Figure 2a). Although the mass was larger than most ductal cysts, no imminent airway obstruction was present. Normal arytenoid and vocal cord mobility were noted despite acquiring only a partial view of the glottis due to the obstruction caused by the mass.