Role of Laryngeal Ultrasonography in screening for laryngeal diseases in symptomatic patients

Background Laryngoscopy is widely considered the most appropriate tool for evaluating the larynx, however, it is invasive and not all patients can tolerate it. Although laryngeal ultrasound has been proposed as a promising noninvasive technique that can play an important role in laryngeal imaging, there is lack of consensus regarding its role. Objective The aim of this study is to assess laryngeal ultrasound sensitivity compared to indirect laryngoscopy in screening for laryngeal diseases in symptomatic patients. Patients and methods 30 undiagnosed symptomatic patients underwent laryngeal ultrasound and indirect laryngoscopy. Their results were compared. Results Technical success rate of laryngeal ultrasound was (83%). It showed overall sensitivity of (78.9%) in detecting organic laryngeal diseases with high sensitivity in detecting laryngeal masses, reinke’s edema, vocal cord cysts and polyps (100%), vocal cord palsy (83.3%), intermediate sensitivity for vocal cord nodules (66.7%), and poor sensitivity for laryngitis and non organic voice disorders (0%). Conclusion Laryngeal ultrasound is a useful non invasive imaging tool that can be used with acceptable sensitivity in detecting organic laryngeal diseases excluding laryngitis, hindered mainly by complete thyroid cartilage calcification in older males. Consequently we recommend its use as complementary to clinical examination and mirror laryngoscopy, or as an alternative to indirect laryngoscopy when required and in routine neck ultrasound exams when appropriate.

Videolaringoscopy Beyond Conventional Endotracheal Intubation in HEMS: A Real Flight Simulation

BackgroundIn pre-hospital setting, airway management may be required during hems transportation, when patients deteriorate while en route. Our primary objective was to assess whether in-flight indirect laryngoscopy in frontal right-lateral sitting position (FP) of the operator, is such effective as traditional indirect laryngoscopy methods onshore, considering, also, the association of success rate with influencing flight factors (flying, devices, position, comfort VAS, Lumen VAS). MethodsThis observational prospective study, aimed to estimate the success rate of in-flight FP indirect laryngoscopy intubation. The study conducted on an AW 169 helicopter (©Leonardo Company, Italy) equipped with transversal stretcher, during steady flight. Indirect laryngoscopy devices (GlideScope Ranger and AirTraq) were used on a HAL® manikin (Accurate, Gaumard® Scientific Company,Inc) with cervical collar. ResultsAll of the FP intubations with both devices were successful after two attempts maximum. The mean time for intubation was slightly greater using the Glide Scope Ranger (mean 45.4±32.2”) compared to AirTraq (mean 34.8±26.7”). ConclusionsBoth AirTraq and GlideScope Ranger used in in-flight FP guarantee a comparable level of effectiveness to traditional onshore method with 100% successful rate of intubation, Airtraq seems not been affected by Lumen, indicating that in this specific contest it guarantees a high visualisation regardless the light conditions. On the other hand, the FP results effective using AirTraq in both conditions.

Comparison of learning direct laryngoscopy using a McGrath videolaryngoscope as a direct versus indirect laryngoscope: a randomized controlled trial

Objective Tracheal intubation using a direct laryngoscope is difficult to teach. The McGrath videolaryngoscope, a Macintosh-like device with a camera, can be used as a direct laryngoscope to educate novices under supervision using the screen. We compared the effect on Macintosh laryngoscopy skills following training with a McGrath videolaryngoscope as a direct versus indirect laryngoscope. Methods Thirty-seven participants were randomized into direct and indirect groups according to the training method using a McGrath videolaryngoscope. Participants attempted Macintosh direct laryngoscopy in normal and difficult airway scenarios. The primary endpoint was the intubation time, and the rate of successful intubation, dental trauma, and difficulty were secondary outcomes. Results The intubation time after education decreased significantly in both groups and was significantly shorter in the direct group than in the indirect group across time. The difficulty degree in the direct group was lower than that in the indirect group across time; however, the rate of dental trauma was not significantly different. Conclusion Both direct and indirect laryngoscopy using a McGrath videolaryngoscope improved the performance of Macintosh direct laryngoscopy in novices, while direct laryngoscopy using a McGrath videolaryngoscope demonstrated better educational effects than indirect laryngoscopy. Registered at ClinicalTrials.gov (NCT03471975).

Voice disorders after total thyroidectomy: Prospective patient self-assessment in comparison with traditional and alternative methods of examining the vocal folds

Background Voice alterations after thyroidectomy with mobile vocal folds are common. Ultrasonography has been used to assess the mobility of the vocal folds after thyroidectomy. Methods 54 patients underwent thyroidectomy. Indirect laryngoscopy, ultrasonography and GRBAS scoring were performed preoperatively,3 days, 2 and 6 months postoperatively. Results On the third postoperative day, the mobility of the vocal folds was preserved in 52 patients and paresis were recorded in 2 patients. All patients after total thyroidectomy noted the presence of voice alteration in the absence of the postoperative paresis of the vocal folds. On the third postoperative day, the voice was impaired by all criteria of the GRBAS scale, but mainly due to roughness (85%). Sixth month postoperatively 62% of the subjects considered the voice to be altered. Asthenia was observed in 39%. On the third postoperative day indirect laryngoscopy revealed the unchanged vocal folds, the symmetrical edema and the shortening of one of the vocal folds in 56%,42% and 1.9%. Six months postoperatively, the vocal folds returned to their original form. Ultrasonography was well correlated to the results of indirect laryngoscopy. Patients with edema of the vocal folds had a significantly higher mean GRBAS grade than patients without edema. The mean GRBAS score decreased from 3.36 to 0.90, 3 days and 6 months postoperatively. Conclusion Voice alteration after total thyroidectomy is always present. Postoperative edema represents a likely main cause of voice alteration and resolves within 6 months. Ultrasonography is recommended as alternative to indirect laryngoscopy in assessing of the vocal folds in thyroid surgery patients.

¿Equivale una mejor visión a una mejor intubación? Artículo original: MazzinariG, Rovira L, Henao L, Ortega J, Casasempere A, Fernandez Y. Effect of Dynamic Versus Stylet-Guided Intubation on First-Attempt Success in Difficult Airways Undergoing Glidescope Laryngoscopy: A Randomized Controlled Trial. Anesthesia-Analgesia. June 2019.Volume 128.Number 6.

El fracaso de intubación en un paciente con Vía Aérea Difícil (VAD) todavía no es infrecuente, es por ello que la amplia utilización de dispositivos de rescate de la laringoscopia directa sigue en auge. Es en este ámbito donde cobran fuerza los videolaringoscopios, que ofrecen una laringoscopia indirecta a través de un montaje multivariado de lentes y ópticas. Los videolaringoscopios nos han aportado en la especialidad de Anestesiología una visión enormemente nítida en muchos casos de glotis prácticamente imposibles, mejorando por tanto el grado de visibilidad ( clasificado en la Escala de Cormack-Lehane), pero esta ventaja no siempre conduce a un aumento en la tasa de éxito de intubación traqueal, debido a que la adecuada inserción del tubo a través de las cuerdas vocales es un factor limitante. Por ello se precisa de guías que permitan dar al tubo endotraqueal una forma adecuada para una correcta intubación. En este estudio se pretende evaluar la tasa de éxito con un videolaringoscopio usando una guía tradicional preformada con cierto ángulo de movilidad anteroposterior vs guía flexible que permite movilidad anteroposterior y lateral como es un fibrobroncospio con la fibra óptica apagada. Los resultados muestran una mejor tasa éxito en la intubación en el primer intento y menor tasa de complicaciones en el manejo de las vías respiratorias. ABSTRACT Better vision makes better intubation? The failure of intubation in a patient with Difficult Airway (VAD) is not yet uncommon, which is why the wide use of rescue devices for direct laryngoscopy is still booming. It is in this area where videolaryngoscopy gain strength, offering indirect laryngoscopy through a multivariate assembly of lenses and optics. Videolaryngoscopy have given us in Anesthesiology an enormously clear vision in many cases of practically impossible glottis, thus improving the degree of visibility (classified in the Cormack-Lehane Scale), but this advantage does not always lead to an increase in the success rate of tracheal intubation, due to the proper insertion of the tube through the vocal cords is a limiting factor. Therefore, stylet-guides are required that need to give the endotracheal tube a suitable form for proper intubation. In this study, it is expected to evaluate the success rate with a videolaryngoscope using a traditional preformed stylet-guide with a certain angle of anteroposterior mobility vs. flexible guidance that allows anteroposterior and lateral mobility such as a fiberscope with the optical fiber turned off. The results experienced a better success rate in intubation on the first attempt and a lower rate of complications in airway management with glidescope+fiberscope.

Prediction of different airway gradings in T1-2 laryngeal cancer with anterior vocal commissure involvement

Background: A retrospective analysis was conducted to investigate the clinical efficacy of the modified Mallampati test (MMT) combined with indirect laryngoscopy in measuring glottic exposure levels of early glottic laryngeal carcinoma (T1-2) with anterior vocal commissure involvement.Methods: One hundred eighty-two patients with early glottic laryngeal cancer were divided into two groups: one group comprised patients treated with transoral carbon dioxide laser microsurgery (TLM, 65 patients), and the other group comprised patients treated with open partial laryngectomy (OPL, 117 patients). The MMT and indirect laryngoscopy were used to re-evaluate the level of glottic exposure and to classify the patients based on these levels. The local control and disease-free survival rates of those patients were measured based on their MMT and indirect laryngoscopy classifications.Results: The 5-year local control rate was significantly different between the two groups according to the MMT (log-rank test: χ2=4.020, P=0.045, 90.9% in the OPL group vs. 71.4% in the TLM group). For patients diagnosed with grade IV tumors using indirect laryngoscopy, the 5-year local control rate was significantly different between the two groups (log-rank test: χ2=4.076, P=0.044, 91.7% in the OPL group vs. 54.7% in the TLM group). Among patients diagnosed with grade III or IV tumors using indirect laryngoscopy and with class III or IV tumors using MMT, the 5-year local control rate was significantly different between the two groups (log-rank test: χ 2 = 8.037, P = 0.005, 97.14% in the OPL group vs. 75.47% in the TLM groups).Conclusions: The combination of the MMT and indirect laryngoscopy to evaluate difficult airways is relatively simple and is very useful for surgeons to better prepare for surgery.Trial registration: ChiCTR-ORC-17010515

Clinical evaluation of disorders of voice

<p class="abstract"><strong>Background:</strong> Disorders of the voice commonly affect the quality of life of the person. The objective of the study was to find out the incidence and features of disorders of vocal cords presented in the OPD with hoarseness of voice.</p><p class="abstract"><strong>Methods:</strong> A study comprising of 45 cases of hoarseness of voice is carried out in the department of otorhinolaryngology in SNMC Bagalkot between January 2018 to June 2019 to evaluate the disorders of change in voice. A total of 45 patients came to OPD and indirect laryngoscopy was done to the patient and confirmed with flexible fibreoptic examination. </p><p class="abstract"><strong>Results:</strong> Age of patients ranges between 8-75 years. There was a slight male predominance seen in the study. Housewives (29%) constitutes single largest group followed by farmers (22%), teachers and labourers. Duration ranges from 6 days to 15 years with 64% patients present with more than 3 months of duration. Voice abuse constitutes single largest precipitating factors followed by tobacco and smoking along with gastrolaryngeal reflex. 78% have single habits and 22% have multiple habits.</p><p class="abstract"><strong>Conclusions:</strong> Maximum no of patients were of infectious group followed by benign lesions and laryngeal palsy.</p><p class="abstract"> </p>

White papilloma involving both vocal cords: A Case Report

White papilloma are rare lesions that may occur at any site of mucosa- lined respiratory tract especially in vocal cords. Morphologically it appears villas looking, clinically & microscopically benign in most cases. We report a 70 years old male patient with white papilloma near anterior commissure involving both vocal cords found during indirect laryngoscopy. The lesion was completely resected with a unipolar coagulation device under direct laryngoscopy. Histopathological examination showed papilloma of vocal cords associated with Human papilloma virus(HPV) wart. To our knowledge this is the second reported case concomitant white papilloma with concomitant HPV in the vocal cords. Bangladesh J Otorhinolaryngol; April 2020; 26(1): 73-76

Relevance of indirect laryngoscopy as an examination tool in present day otorhinolaryngological practice

<p class="abstract"><strong>Background:</strong> The objective of the study was to determine the difference in extent of laryngeal visualization between indirect laryngoscopy (IDL) mirror and rigid endoscopy (70°) and relevance of IDL in present day otolaryngological practice.</p><p class="abstract"><strong>Methods:</strong> 100 patients attending to the Department of ENT, Vijayanagara Institute of Medical Sciences, Ballari, Karnataka with complaints referable to larynx and upper digestive tract were taken up for study. All patients underwent IDL mirror and rigid endoscopic (4 mm, 70°) examination. The extent of laryngeal visualization by the clinician was recorded for each examination. </p><p class="abstract"><strong>Results:</strong> Out of 100 patients who underwent IDL mirror examination and rigid endoscopic (4 mm, 70°) examination in 87% of cases IDL mirror examination was adequate for making the diagnosis and in 11% of cases we needed rigid endoscopic examination for making the diagnosis. In 2% of cases we were not able to visualize the pathologies even with rigid endoscopy, in whom we needed other modalities of examination like radiological evidence to arrive at a diagnosis.</p><p class="abstract"><strong>Conclusions:</strong> In the present study, in 87% of the cases IDL mirror examination was adequate for making the diagnosis. Eleven cases needed rigid endoscopic (4 mm, 70°) examination to aid in diagnosis of pathologies. Even though laryngeal mirror examination is less comfortable, causing gagging for patient and may provide less complete information when compared to rigid endoscopy because of its less expensive, better depth visualization of structures and near real size images provides a versatile tool till date. Be that as it may indirect laryngoscopic mirror examination remains the mainstay of otolaryngological practice in today’s Otolaryngology practice.</p>