1
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Jeppesen K, Philipsen BB, Mehlum CS. Prevalence and characterisation of exercise-induced laryngeal obstruction in patients with exercise-induced dyspnoea. J Laryngol Otol 2024; 138:208-215. [PMID: 37646338 PMCID: PMC10849894 DOI: 10.1017/s0022215123001494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/03/2023] [Accepted: 07/18/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE The prevalence of exercise-induced laryngeal obstruction is largely unknown. This study aimed to evaluate the prevalence of this condition in a selected study population of patients with exercise-induced dyspnoea. METHOD A retrospective analysis was conducted of demographic data, co-morbidities, medication, symptoms, performance level of sporting activities, continuous laryngoscopy exercise test results and subsequent treatment. RESULTS Data from 184 patients were analysed. The overall prevalence of exercise-induced laryngeal obstruction in the study population was 40 per cent, and the highest prevalence was among females aged under 18 years (61 per cent). However, a high prevalence among males aged under 18 years (50 per cent) and among adults regardless of gender (34 per cent) was also found. CONCLUSION The prevalence of exercise-induced laryngeal obstruction is clinically relevant regardless of age and gender. Clinicians are encouraged to consider exercise-induced laryngeal obstruction as a possible diagnosis in patients suffering from exercise-induced respiratory symptoms. No single characteristic that can distinguish exercise-induced laryngeal obstruction from other similar conditions was identified.
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Affiliation(s)
- Karin Jeppesen
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Southern Denmark, Sønderborg, Denmark
| | - Bahareh Bakhshaie Philipsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
| | - Camilla Slot Mehlum
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
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2
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Dreßler M, Lassmann H, Eichhorn C, Trischler J, Hutter M, Zielen S, Schulze J. Are Questionnaires Helpful To Predict Exercise-Induced Bronchoconstriction (EIB) And Exercise-Induced Laryngeal Obstruction (EILO)? KLINISCHE PADIATRIE 2024; 236:139-144. [PMID: 38286408 DOI: 10.1055/a-2151-2269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
OBJECTIVE Exercise induced laryngeal obstruction (EILO) is an important differential diagnosis to exercise induced bronchoconstriction (EIB) and diagnosed via continuous laryngoscopy while exercising (CLE). However, availability of CLE is limited to specialized centres. And without CLE EILO is often misdiagnosed as EIB. Therefore it is essential to carefully preselect potential EILO candidates. Aim of this study was to investigate whether two short questionnaires -Asthma Control Test (ACT) and Dyspnea Index (DI) evaluating upper airway-related dyspnea- can differentiate between EIB and EILO. METHODS Patients with dyspnea while exercising were analysed with an exercise challenge in the cold chamber (ECC) to diagnose EIB in visit 1 (V1), as appropriate a CLE in visit 2 (V2, 4-6 weeks after V1) and ACT and DI in V1 and V2. EIB patients were treated with asthma medication after V1. RESULTS Complete dataset of 36 subjects were gathered. The ACT showed lower values in V2 in EILO compared to EIB patients. A lack of improvement in ACT in V2 after asthma medication of EIB patients is suspicious for additional EILO diagnosis. The DI showed higher values in V1 in EILO compared to EIB patients. A score≥30 can predict a positive CLE reaction. CONCLUSION ACT and DI are valuable tools in preselecting CLE candidates to assure timely diagnostic despite limited diagnostic capabilities.
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Affiliation(s)
- Melanie Dreßler
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Hannah Lassmann
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Celine Eichhorn
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Jordis Trischler
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Martin Hutter
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Stefan Zielen
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Johannes Schulze
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
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3
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Fujiki RB, Lunga T, Francis DO, Thibeault SL. Economic Burden of Induced Laryngeal Obstruction in Adolescents and Children. Laryngoscope 2024. [PMID: 38230958 DOI: 10.1002/lary.31281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/13/2023] [Accepted: 01/03/2024] [Indexed: 01/18/2024]
Abstract
PURPOSE Diagnosing pediatric induced laryngeal obstruction (ILO) requires equipment typically available in specialist settings, and patients often see multiple providers before a diagnosis is determined. This study examined the financial burden associated with the diagnosis and treatment of ILO in pediatric patients with reference to socioeconomic disadvantage. METHODS Adolescents and children (<18 years of age) diagnosed with ILO were identified through the University of Madison Voice and Swallow Outcomes Database. Procedures, office visits, and prescribed medications were collected from the electronic medical record. Expenditures were calculated for two time periods (1) pre-diagnosis (first dyspnea-related visit to diagnosis), and (2) the first year following diagnosis. The Area Deprivation Index (ADI) was used to estimate patient socioeconomic status to determine if costs differed with neighborhood-level disadvantage. RESULTS A total of 113 patients met inclusion criteria (13.9 years, 79% female). Total pre-diagnosis costs of ILO averaged $6486.93 (SD = $6604.14, median = $3845.66) and post-diagnosis costs averaged $2067.69 (SD = $2322.78; median = $1384.12). Patients underwent a mean of 3.01 (SD = 1.9; median = 2) procedures and 5.8 (SD = 4.7; median = 5) office visits prior to diagnosis. Pharmaceutical, procedure/office visit, and indirect costs significantly decreased following diagnosis. Patients living in neighborhoods with greater socioeconomic disadvantage underwent fewer procedures and were prescribed more medication than those from more affluent areas. However, total expenditures did not differ based on ADI. CONCLUSIONS Pediatric ILO is associated with considerable financial costs. The source of these costs, however, differed according to socioeconomic advantage. Future work should determine how ILO diagnosis and management can be more efficient and equitable across all patients. Laryngoscope, 2024.
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Affiliation(s)
| | - Tadeas Lunga
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
| | - David O Francis
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
| | - Susan L Thibeault
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
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4
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Leng T, Wiedermann J, Cofer S, Pillai S. The Clinical Utility of Continuous Laryngoscopy During Exercise: A Report of Two Cases. Cureus 2023; 15:e50572. [PMID: 38222221 PMCID: PMC10788043 DOI: 10.7759/cureus.50572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/16/2024] Open
Abstract
Exertional dyspnea is a common and disabling symptom in otherwise healthy children and adolescents, as well as in children with baseline airway abnormalities. It impairs the quality of life and may be associated with fatigue and underperformance in sports. Exertional dyspnea can be caused by a wide variety of structural and psychogenic causes. Exercise-induced laryngeal obstruction (EILO) is a relatively prevalent entity in young people that usually presents with exertional stridor, coughing, and dyspnea caused by transient closure of the larynx. In more complex cases where conventional tests such as pulmonary function tests (PFTs), chest imaging, ECG, and echocardiography are unrevealing, continuous laryngoscopy during exercise (CLE) tests may provide diagnostic utility. In addition to the baseline abnormalities visualized by conventional laryngoscopy, CLE can assess dynamic laryngeal responses during exercise. This article describes the clinical characteristics of two pediatric patients with various degrees of laryngeal dysfunction at baseline and the utility of CLE testing in tailoring management strategies.
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Affiliation(s)
- Tomas Leng
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, USA
| | - Joshua Wiedermann
- Department of Pediatric Otorhinolaryngology, Mayo Clinic, Rochester, USA
| | - Shelagh Cofer
- Department of Pediatric Otorhinolaryngology, Mayo Clinic, Rochester, USA
| | - Sophia Pillai
- Department of Pediatric Pulmonary Medicine, Mayo Clinic, Rochester, USA
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5
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Irewall T, Bäcklund C, Naumburg E, Ryding M, Stenfors N. A longitudinal follow-up of continuous laryngoscopy during exercise test scores in athletes irrespective of laryngeal obstruction, respiratory symptoms, and intervention. BMC Sports Sci Med Rehabil 2023; 15:87. [PMID: 37454093 DOI: 10.1186/s13102-023-00681-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Exercise-induced laryngeal obstruction (EILO) is diagnosed by the continuous laryngoscopy during exercise (CLE) test. Whether or how much CLE test scores vary over time is unknown. This study aimed to compare CLE test scores in athletes over time, irrespective of respiratory symptoms and grade of laryngeal obstruction. METHODS Ninety-eight athletes previously screened for EILO were invited for a follow-up CLE test irrespective of CLE scores and respiratory symptoms. Twenty-nine athletes aged 16-27 did a follow-up CLE test 3-23 months after the baseline test. Laryngeal obstruction at the glottic and supraglottic levels was graded by the observer during exercise, at baseline and follow-up, using a visual grade score (0-3 points). RESULTS At baseline, 11 (38%) of the 29 athletes had moderate laryngeal obstruction and received advice on breathing technique; among them, 8 (73%) reported exercise-induced dyspnea during the last 12 months. At follow-up, 8 (73%) of the athletes receiving advice on breathing technique had an unchanged supraglottic score. Three (17%) of the 18 athletes with no or mild laryngeal obstruction at baseline had moderate supraglottic obstruction at follow-up, and none of the 3 reported exercise-induced dyspnea. CONCLUSIONS In athletes with repeated testing, CLE scores remain mostly stable over 3-24 months even with advice on breathing technique to those with EILO. However, there is some intraindividual variability in CLE scores over time. TRIAL REGISTRATION ISRCTN, ISRCTN60543467, 2020/08/23, retrospectively registered, ISRCTN - ISRCTN60543467: Investigating conditions causing breathlessness in athletes.
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Affiliation(s)
- Tommie Irewall
- Division of Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Catharina Bäcklund
- Unit of Physiotherapy, Östersund Hospital, Region Jämtland Härjedalen, Östersund, Sweden
| | - Estelle Naumburg
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Marie Ryding
- Unit of Otorhinolaryngology, Östersund Hospital, Region Jämtland Härjedalen, Östersund, Sweden
| | - Nikolai Stenfors
- Division of Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
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6
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Schwellnus M, Adami PE, Bougault V, Budgett R, Clemm HH, Derman W, Erdener U, Fitch K, Hull JH, McIntosh C, Meyer T, Pedersen L, Pyne DB, Reier-Nilsen T, Schobersberger W, Schumacher YO, Sewry N, Soligard T, Valtonen M, Webborn N, Engebretsen L. International Olympic Committee (IOC) consensus statement on acute respiratory illness in athletes part 2: non-infective acute respiratory illness. Br J Sports Med 2022; 56:bjsports-2022-105567. [PMID: 35623888 DOI: 10.1136/bjsports-2022-105567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 01/03/2023]
Abstract
Acute respiratory illness (ARill) is common and threatens the health of athletes. ARill in athletes forms a significant component of the work of Sport and Exercise Medicine (SEM) clinicians. The aim of this consensus is to provide the SEM clinician with an overview and practical clinical approach to non-infective ARill in athletes. The International Olympic Committee (IOC) Medical and Scientific Committee appointed an international consensus group to review ARill in athletes. Key areas of ARill in athletes were originally identified and six subgroups of the IOC Consensus group established to review the following aspects: (1) epidemiology/risk factors for ARill, (2) infective ARill, (3) non-infective ARill, (4) acute asthma/exercise-induced bronchoconstriction and related conditions, (5) effects of ARill on exercise/sports performance, medical complications/return-to-sport (RTS) and (6) acute nasal/laryngeal obstruction presenting as ARill. Following several reviews conducted by subgroups, the sections of the consensus documents were allocated to 'core' members for drafting and internal review. An advanced draft of the consensus document was discussed during a meeting of the main consensus core group, and final edits were completed prior to submission of the manuscript. This document (part 2) of this consensus focuses on respiratory conditions causing non-infective ARill in athletes. These include non-inflammatory obstructive nasal, laryngeal, tracheal or bronchial conditions or non-infective inflammatory conditions of the respiratory epithelium that affect the upper and/or lower airways, frequently as a continuum. The following aspects of more common as well as lesser-known non-infective ARill in athletes are reviewed: epidemiology, risk factors, pathology/pathophysiology, clinical presentation and diagnosis, management, prevention, medical considerations and risks of illness during exercise, effects of illness on exercise/sports performance and RTS guidelines.
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Affiliation(s)
- Martin Schwellnus
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- SEMLI, IOC Research Centre, Pretoria, Gauteng, South Africa
| | - Paolo Emilio Adami
- Health & Science Department, World Athletics, Monaco, Monaco Principality
| | - Valerie Bougault
- Laboratoire Motricité Humaine Expertise Sport Santé, Université Côte d'Azur, Nice, Provence-Alpes-Côte d'Azu, France
| | - Richard Budgett
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Hege Havstad Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Wayne Derman
- Institute of Sport and Exercise Medicine (ISEM), Department of Sport Science, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- ISEM, IOC Research Center, South Africa, Stellenbosch, South Africa
| | - Uğur Erdener
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Ken Fitch
- School of Human Science; Sports, Exercise and Health, The University of Western Australia, Perth, Western Australia, Australia
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Institute of Sport, Exercise and Health (ISEH), University College London (UCL), London, UK
| | - Cameron McIntosh
- Dr CND McIntosh INC, Edge Day Hospital, Port Elizabeth, South Africa
| | - Tim Meyer
- Institute of Sports and Preventive Medicine, Saarland University, Saarbrucken, Germany
| | - Lars Pedersen
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - David B Pyne
- Research Institute for Sport and Exercise, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Tonje Reier-Nilsen
- Oslo Sports Trauma Research Centre, The Norwegian Olympic Sports Centre, Oslo, Norway
- Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Wolfgang Schobersberger
- Insitute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), Kliniken Innsbruck and Private University UMIT Tirol, Hall, Austria
| | | | - Nicola Sewry
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- SEMLI, IOC Research Centre, Pretoria, Gauteng, South Africa
| | - Torbjørn Soligard
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, Calgary, Alberta, Canada
| | - Maarit Valtonen
- KIHU, Research Institute for Olympic Sports, Jyväskylä, Finland
| | - Nick Webborn
- Centre for Sport and Exercise Science and Medicine, University of Brighton, Brighton, UK
| | - Lars Engebretsen
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
- Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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7
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Clemm HH, Olin JT, McIntosh C, Schwellnus M, Sewry N, Hull JH, Halvorsen T. Exercise-induced laryngeal obstruction (EILO) in athletes: a narrative review by a subgroup of the IOC Consensus on 'acute respiratory illness in the athlete'. Br J Sports Med 2022; 56:622-629. [PMID: 35193856 PMCID: PMC9120388 DOI: 10.1136/bjsports-2021-104704] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 02/06/2023]
Abstract
Exercise-induced laryngeal obstruction (EILO) is caused by paradoxical inspiratory adduction of laryngeal structures during exercise. EILO is an important cause of upper airway dysfunction in young individuals and athletes, can impair exercise performance and mimic lower airway dysfunction, such as asthma and/or exercise-induced bronchoconstriction. Over the past two decades, there has been considerable progress in the recognition and assessment of EILO in sports medicine. EILO is a highly prevalent cause of unexplained dyspnoea and wheeze in athletes. The preferred diagnostic approach is continuous visualisation of the larynx (via laryngoscopy) during high-intensity exercise. Recent data suggest that EILO consists of different subtypes, possibly caused via different mechanisms. Several therapeutic interventions for EILO are now in widespread use, but to date, no randomised clinical trials have been performed to assess their efficacy or inform robust management strategies. The aim of this review is to provide a state-of-the-art overview of EILO and guidance for clinicians evaluating and treating suspected cases of EILO in athletes. Specifically, this review examines the pathophysiology of EILO, outlines a diagnostic approach and presents current therapeutic algorithms. The key unmet needs and future priorities for research in this area are also covered.
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Affiliation(s)
- Hege Havstad Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland Universityhospital, Bergen, Norway .,Faculty of Medicine and Dentistry, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - J Tod Olin
- Department of Pediatrics and Medicine, National Jewish Health, Denver, Colorado, USA
| | | | - Martin Schwellnus
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,IOC Research Centre, South Africa
| | - Nicola Sewry
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,IOC Research Centre, South Africa
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Thomas Halvorsen
- Department of Pediatric and Adolescent Medicine, Haukeland Universityhospital, Bergen, Norway.,Faculty of Medicine and Dentistry, Department of Clinical Science, University of Bergen, Bergen, Norway.,Norwegian School of Sports Sciences, Oslo, Norway
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8
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Clemm H, Røksund OD, Andersen T, Heimdal JH, Karlsen T, Hilland M, Fretheim-Kelly Z, Hufthammer KO, Sandnes A, Hjelle S, Vollsæter M, Halvorsen T. Exercise-induced Laryngeal Obstruction: Protocol for a Randomized Controlled Treatment Trial. Front Pediatr 2022; 10:817003. [PMID: 35198517 PMCID: PMC8858975 DOI: 10.3389/fped.2022.817003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/10/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathing problems in young individuals, caused by paradoxical inspiratory adduction of laryngeal structures, and diagnosed by continuous visualization of the larynx during high-intensity exercise. Empirical data suggest that EILO consists of different subtypes, possibly requiring different therapeutic approaches. Currently applied treatments do not rest on randomized controlled trials, and international guidelines based on good evidence can therefore not be established. This study aims to provide evidence-based information on treatment schemes commonly applied in patients with EILO. METHODS AND ANALYSIS Consenting patients consecutively diagnosed with EILO at Haukeland University Hospital will be randomized into four non-invasive treatment arms, based on promising reports from non-randomized studies: (A) standardized information and breathing advice only (IBA), (B) IBA plus inspiratory muscle training, (C) IBA plus speech therapy, and (D) IBA plus inspiratory muscle training and speech therapy. Differential effects in predefined EILO subtypes will be addressed. Patients failing the non-invasive approach and otherwise qualifying for surgical treatment by current department policy will be considered for randomization into (E) standard or (F) minimally invasive laser supraglottoplasty or (G) no surgery. Power calculations are based on the main outcomes, laryngeal adduction during peak exercise, rated by a validated scoring system before and after the interventions. ETHICS AND DISSEMINATION The study will assess approaches to EILO treatments that despite widespread use, are insufficiently tested in structured, verifiable, randomized, controlled studies, and is therefore considered ethically sound. The study will provide knowledge listed as a priority in a recent statement issued by the European Respiratory Society, requested by clinicians and researchers engaged in this area, and relevant to 5-7% of young people. Dissemination will occur in peer-reviewed journals, at relevant media platforms and conferences, and by engaging with patient organizations and the healthcare bureaucracy.
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Affiliation(s)
- Hege Clemm
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ola D Røksund
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Otolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - Tiina Andersen
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway.,Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tom Karlsen
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Magnus Hilland
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Zoe Fretheim-Kelly
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oslo, Norway
| | | | - Astrid Sandnes
- Department of Internal Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Sigrun Hjelle
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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9
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Olin JT, Shaffer M, Nauman E, Durso CS, Fan EM, Staudenmayer H, Christopher KL, Gartner-Schmidt J. Development and validation of the Exercise-Induced Laryngeal Obstruction Dyspnea Index (EILODI). J Allergy Clin Immunol 2021; 149:1437-1444. [PMID: 34619181 DOI: 10.1016/j.jaci.2021.09.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Exercise-induced laryngeal obstruction (EILO) causes exertional dyspnea and is important for its effect on quality of life, diagnostic confusion with exercise-induced asthma, and health care resource utilization. There is no validated patient-reported outcome measure specific to EILO. OBJECTIVE We sought to develop, validate, and define a minimal clinically important difference for a patient-reported outcome measure to be used with adolescents and young adults with EILO. METHODS A multidisciplinary group created a preliminary measure, modified by a 10-member participant focus group, with 20 items scored along a 5-point Likert scale. A subsequent cohort of participants recruited from a clinic, aged 12 to 21 years, with confirmed EILO by continuous laryngoscopy during exercise testing (1) completed the measure at 3 points in time over 28 days and (2) provided anchoring data in the form of a daily exercise log and categorical self-assessments of clinical improvement. Thirty additional participants without exertional dyspnea served as controls. RESULTS Two hundred nineteen subjects with mild to severe EILO participated in the exploratory factor analysis, which identified 7 factors within the preliminary outcome measure. After a process of item reduction, a 12-item metric with a total score ranging from 0 to 48 was developed. Mean scores of patients with EILO and healthy controls at baseline were 28.8 ± 7.4 and 4.5 ± 7.4, respectively. A minimal clinically important difference of 6 was determined by comparison of index change with changes in categorical self-assessments of improvement. CONCLUSIONS This is the first patient-reported outcome measure specifically designed for adolescents and young adults with EILO.
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Affiliation(s)
- James Tod Olin
- Department of Pediatrics, National Jewish Health, Denver, Colo; Department of Medicine, National Jewish Health, Denver, Colo.
| | - Monica Shaffer
- Department of Rehabilitation Medicine, National Jewish Health, Denver, Colo
| | - Emily Nauman
- Department of Rehabilitation Medicine, National Jewish Health, Denver, Colo
| | | | - Elizabeth M Fan
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Herman Staudenmayer
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colo
| | - Kent L Christopher
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colo
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10
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Walsted ES, Famokunwa B, Andersen L, Rubak SL, Buchvald F, Pedersen L, Dodd J, Backer V, Nielsen KG, Getzin A, Hull JH. Characteristics and impact of exercise-induced laryngeal obstruction: an international perspective. ERJ Open Res 2021; 7:00195-2021. [PMID: 34195253 PMCID: PMC8236618 DOI: 10.1183/23120541.00195-2021] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/12/2021] [Indexed: 01/21/2023] Open
Abstract
Background Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathlessness and wheeze yet is frequently misdiagnosed as asthma. Insight regarding the demographic characteristics, laryngeal abnormalities and impact of EILO is currently limited, with data only available from individual centre reports. The aim of this work was to provide a broader perspective from a collaboration between multiple international expert centres. Methods Five geographically distinct clinical paediatric and adult centres (3 Denmark, 1 UK, 1 USA) with an expertise in assessing unexplained exertional breathlessness completed database entry of key characteristic features for all cases referred with suspected EILO over a 5-year period. All included cases completed clinical asthma workup and continuous laryngoscopy during exercise (CLE) testing for EILO. Results Data were available for 1007 individuals (n=713 female (71%)) with a median (range) age of 24 (8–76) years, and of these 586 (58%) were diagnosed with EILO. In all centres, EILO was frequently misdiagnosed as asthma; on average there was a 2-year delay to diagnosis of EILO, and current asthma medication was discontinued in 20%. Collapse at the supraglottic level was seen in 60%, whereas vocal cord dysfunction (VCD) was only detected/visualised in 18%. Nearly half (45%) of individuals with EILO were active participants in recreational-level sports, suggesting that EILO is not simply confined to competitive/elite athletes. Conclusion Our findings indicate that key clinical characteristics and the impact of EILO/VCD are similar in globally distinct regions, facilitating improved awareness of this condition to enhance recognition and avoid erroneous asthma treatment. Exercise-induced laryngeal obstruction is a prevalent cause of exertional breathlessness and wheeze. In this international multicentre collaboration, 1007 patients waited, on average, 2 years for diagnosis and 20% were mistreated as asthmatic.https://bit.ly/3auXpcp
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Affiliation(s)
- Emil S Walsted
- Dept of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark.,Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Bamidele Famokunwa
- Academic Respiratory Unit, University of Bristol, Southmead Hospital, Bristol, UK
| | - Louise Andersen
- Dept of Pediatrics and Adolescent Medicine, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Sune L Rubak
- Dept of Pediatrics and Adolescent Medicine, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Frederik Buchvald
- Pediatric Pulmonary Service, Dept of Pediatrics and Adolescent Medicine, Rigshospitalet, Denmark
| | - Lars Pedersen
- Dept of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - James Dodd
- Academic Respiratory Unit, University of Bristol, Southmead Hospital, Bristol, UK
| | - Vibeke Backer
- Dept of ENT and Centre for Physical Activity Research, Rigshospitalet and Copenhagen University, Copenhagen, Denmark
| | - Kim G Nielsen
- Pediatric Pulmonary Service, Dept of Pediatrics and Adolescent Medicine, Rigshospitalet, Denmark.,Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - James H Hull
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
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11
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Sandage MJ, Dunn LA, Edwards R, Pope SA. Implications of Compression Race Suit on Forced Vital Capacity: Assessment Considerations for Paradoxical Vocal Fold Motion in Competitive Female Swimmers. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 29:732-740. [PMID: 32202914 DOI: 10.1044/2019_ajslp-19-00185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Purpose The purpose of this investigation was to quantify the extent to which forced vital capacity (FVC) in competitive swimmers may differ from nonswimmers and determine if compression race suits reduced FVC when compared to practice swimsuits. Identification of the differences in FVC between swimmers and nonswimmers as well as pulmonary function differences secondary to swimsuit construction may inform assessment of the competitive swimmer with paradoxical vocal fold motion (PVFM). Method Using a prospective, mixed within- and between-groups, repeated measures design with 10 female competitive swimmers and 13 female nonswimmers, FVC was measured and compared between the two groups. Further FVC assessment was completed with the swimmers to identify FVC differences between a practice suit and a compression racing suit. Results FVC in swimmers was significantly larger than FVC in nonswimmers by over 1 L. The predicted FVC volumes were significantly smaller than the actual FVC volumes for swimmers. No significant differences were identified between the practice swimsuit and the compression race suit or between the predicted and actual FVCs for the nonswimmer group. Conclusions Swimmers have unique pulmonary function and physiology that require consideration during the assessment for PVFM to ascertain the extent to which the pulmonary system may be compromised from PVFM, reduced exercise intensity, or both. Knowledge of differential diagnoses and adequate characterization of pulmonary volumes in swimmers will improve assessment processes.
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Affiliation(s)
- Mary J Sandage
- Department of Communication Disorders, Auburn University, AL
| | - Lauren A Dunn
- Department of Communication Disorders, Auburn University, AL
| | - Ryleigh Edwards
- Department of Communication Disorders, Auburn University, AL
| | - Sara Ann Pope
- Department of Communication Disorders, Auburn University, AL
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12
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Hull JH, Godbout K, Boulet LP. Exercise-Associated Dyspnea and Stridor: Thinking Beyond Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2202-2208. [PMID: 32061900 DOI: 10.1016/j.jaip.2020.01.057] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 12/26/2022]
Abstract
Breathlessness during sport can be caused by various cardiorespiratory conditions, but when associated with stridor, usually arises from an upper airway etiology. The term exercise-induced laryngeal obstruction (EILO) is now used to describe the phenomenon of transient glottic closure occurring in association with physical activity. Exercise-related laryngeal closure is most commonly encountered in athletic individuals and likely affects between 5% and 7% of all young adults and adolescents. The diagnosis of EILO is not always straightforward because features can overlap with exercise-induced asthma/exercise-induced bronchoconstriction. EILO can therefore remain misdiagnosed for years, and most patients receive inappropriate asthma therapy. In contrast with asthma, EILO symptoms are usually most prominent at maximal exercise intensity and resolve quickly on exercise cessation. It is important to recognize that EILO and asthma can coexist in a proportion of athletes. The criterion standard test for diagnosing EILO is continuous laryngoscopy during exercise testing, although eucapnic voluntary hyperpnea testing has also been used. Various surgical or pharmacological interventions can be used to treat EILO, but first-line treatment is breathing technique work. Further research is needed to establish the optimal treatment algorithm, and more work is needed to increase awareness of this important clinical entity.
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Affiliation(s)
- James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Krystelle Godbout
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, Québec, Canada
| | - Louis-Philippe Boulet
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, Québec, Canada.
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13
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Famokunwa B, Sandhu G, Hull JH. Surgical intervention for exercise-induced laryngeal obstruction: A UK perspective. Laryngoscope 2020; 130:E667-E673. [PMID: 31913523 DOI: 10.1002/lary.28497] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/05/2019] [Accepted: 12/12/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Exercise-induced laryngeal obstruction (EILO) is a prevalent cause of exertional breathlessness and wheeze in young individuals. Typically diagnosed using the continuous laryngoscopy during exercise (CLE) test, treatment is largely based on breathing retraining promoting improved laryngeal function. In some cases, these techniques fail to alleviate symptoms, and surgical intervention with supraglottoplasty can be valuable in the supraglottic form of EILO. Globally, there is currently limited experience utilizing a surgical approach to EILO, and data regarding the optimum surgical technique and published outcomes and complication rates are thus limited. STUDY DESIGN Retrospective observational case series. METHODS In this report, we describe our experience as the only UK center undertaking supraglottoplasty for EILO. We report the surgical outcome of 19 patients (n = 16 female), mean age, 29.6 ± 13.1 years, referred for surgery with moderate to severe supraglottic EILO. Follow-up clinic ± CLE was performed within 4 months (median = 6 weeks), and CLE scores were evaluated before and following surgery. RESULTS We found a beneficial effect of surgery on supraglottic CLE scores (median score reducing from 3/3 to 1/3 postoperatively [P < .05] overall) with 79% (n = 15) of patients reporting an improvement in their exercise capacity. One patient developed an apparent increased tendency for glottic-level EILO following surgery; however, no voice- or swallowing-related complications were encountered. CONCLUSIONS This study is the first to report the UK experience, surgical technique, and outcome for EILO surgery. The findings indicate that EILO surgery appears to be a safe and effective option for individuals with moderate to severe supraglottic-type EILO who have failed initial conservative treatment. LEVEL OF EVIDENCE 5 Laryngoscope, 130:E667-E673, 2020.
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Affiliation(s)
- Bamidele Famokunwa
- North Bristol Lung Centre, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Guri Sandhu
- Department of Laryngology, Charing Cross Hospital London, London, United Kingdom
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
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14
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Barker N, Thevasagayam R, Ugonna K, Kirkby J. Pediatric Dysfunctional Breathing: Proposed Components, Mechanisms, Diagnosis, and Management. Front Pediatr 2020; 8:379. [PMID: 32766182 PMCID: PMC7378385 DOI: 10.3389/fped.2020.00379] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022] Open
Abstract
Dysfunctional breathing (DB) is an overarching term describing deviations in the normal biomechanical patterns of breathing which have a significant impact on quality of life, performance and functioning. Whilst it occurs in both children and adults, this article focuses specifically on children. DB can be viewed as having two components; breathing pattern disorder (BPD) and inducible laryngeal obstruction (ILO). They can be considered in isolation, however, are intricately related and often co-exist. When both are suspected, we propose both BPD and ILO be investigated within an all-encompassing multi-disciplinary dysfunctional breathing clinic. The MDT clinic can diagnose DB through expert history taking and a choice of appropriate tests/examinations which may include spirometry, breathing pattern analysis, exercise testing and laryngoscopic examination. Use of the proposed algorithm presented in this article will aid decision making regarding choosing the most appropriate tests and understanding the diagnostic implications of these tests. The most common symptoms of DB are shortness of breath and chest discomfort, often during exercise. Patients with DB typically present with normal spirometry and an altered breathing pattern at rest which is amplified during exercise. In pediatric ILO, abnormalities of the upper airway such as cobblestoning are commonly seen followed by abnormal activity of the upper airway structures provoked by exercise. This may be associated with a varying degree of stridor. The symptoms, however, are often misdiagnosed as asthma and the picture can be further complicated by the common co-presentation of DB and asthma. Associated conditions such as asthma, extra-esophageal reflux, rhinitis, and allergy must be treated appropriately and well controlled before any directed therapy for DB can be started if therapy is to be successful. DB in pediatrics is commonly treated with a course of non-pharmaceutical therapy. The therapy is provided by an experienced physiotherapist, speech and language therapist or psychologist depending on the dominant features of the DB presentation (i.e., BPD or ILO in combination or in isolation) and some patients will benefit from input from more than one of these disciplines. An individualized treatment program based on expert assessment and personalized goals will result in a return to normal function with reoccurrence being rare.
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Affiliation(s)
- Nicki Barker
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Ravi Thevasagayam
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Kelechi Ugonna
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Jane Kirkby
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
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15
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Sandnes A, Hilland M, Vollsæter M, Andersen T, Engesæter IØ, Sandvik L, Heimdal JH, Halvorsen T, Eide GE, Røksund OD, Clemm HH. Severe Exercise-Induced Laryngeal Obstruction Treated With Supraglottoplasty. Front Surg 2019; 6:44. [PMID: 31417908 PMCID: PMC6684966 DOI: 10.3389/fsurg.2019.00044] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/16/2019] [Indexed: 01/29/2023] Open
Abstract
Introduction: Exercise induced laryngeal obstruction (EILO) is relatively common in adolescents, with symptoms often confused with exercise induced asthma. EILO often starts with medial or inward rotation of supraglottic structures of the larynx, whereas glottic adduction appears as a secondary phenomenon in a majority. Therefore, surgical treatment (supraglottoplasty) is used in thoroughly selected and highly motivated patients with pronounced symptoms and severe supraglottic collapse. Aim: To investigate efficacy and safety of laser supraglottoplasty as treatment for severe supraglottic EILO by retrospective chart reviews. Methods: The EILO register at Haukeland University Hospital, Bergen, Norway was used to identify patients who had undergone laser supraglottoplasty for severe supraglottic EILO, verified by continuous laryngoscopy exercise (CLE) test, during 2013–2015. Laser incision in both aryepiglottic folds anterior to the cuneiform tubercles and removal of the mucosa around the top was performed in general anesthesia. Outcomes were questionnaire based self-reported symptoms, and laryngeal obstruction scored according to a defined scheme during a CLE-test performed before and after surgery. Results: Forty-five of 65 eligible patients, mean age 15.9 years, were included. Post-operatively, 38/45 (84%) patients reported less symptoms, whereas CLE-test scores had improved in all, of whom 16/45 (36%) had no signs of obstruction. Most improvements were at the supraglottic level, but 21/45 (47%) also improved at the glottic level. Two of 65 patients had complications; self-limiting vocal fold paresis and scarring/shortening of plica ary-epiglottica. Conclusion: Supraglottoplasty improves symptoms and decreases laryngeal obstruction in patients with severe supraglottic EILO, and appears safe in highly selected cases.
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Affiliation(s)
- Astrid Sandnes
- Department of Internal Medicine, Innlandet Hospital Trust, Gjøvik, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Magnus Hilland
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway
| | - Tiina Andersen
- Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway.,Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway
| | | | - Lorentz Sandvik
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ola Drange Røksund
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hege H Clemm
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
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16
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Slinger C, Mehdi SB, Milan SJ, Dodd S, Matthews J, Vyas A, Marsden PA. Speech and language therapy for management of chronic cough. Cochrane Database Syst Rev 2019; 7:CD013067. [PMID: 31335963 PMCID: PMC6649889 DOI: 10.1002/14651858.cd013067.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cough both protects and clears the airway. Cough has three phases: breathing in (inspiration), closure of the glottis, and a forced expiratory effort. Chronic cough has a negative, far-reaching impact on quality of life. Few effective medical treatments for individuals with unexplained (idiopathic/refractory) chronic cough (UCC) are known. For this group, current guidelines advocate the use of gabapentin. Speech and language therapy (SLT) has been considered as a non-pharmacological option for managing UCC without the risks and side effects associated with pharmacological agents, and this review considers the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of SLT in this context. OBJECTIVES To evaluate the effectiveness of speech and language therapy for treatment of people with unexplained (idiopathic/refractory) chronic cough. SEARCH METHODS We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, trials registries, and reference lists of included studies. Our most recent search was 8 February 2019. SELECTION CRITERIA We included RCTs in which participants had a diagnosis of UCC having undergone a full diagnostic workup to exclude an underlying cause, as per published guidelines or local protocols, and where the intervention included speech and language therapy techniques for UCC. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of 94 records. Two clinical trials, represented in 10 study reports, met our predefined inclusion criteria. Two review authors independently assessed risk of bias for each study and extracted outcome data. We analysed dichotomous data as odds ratios (ORs), and continuous data as mean differences (MDs) or geometric mean differences. We used standard methods recommended by Cochrane. Our primary outcomes were health-related quality of life (HRQoL) and serious adverse events (SAEs). MAIN RESULTS We found two studies involving 162 adults that met our inclusion criteria. Neither of the two studies included children. The duration of treatment and length of sessions varied between studies from four sessions delivered weekly, to four sessions over two months. Similarly, length of sessions varied slightly from one 60-minute session and three 45-minute sessions to four 30-minute sessions. The control interventions were healthy lifestyle advice in both studies.One study contributed HRQoL data, using the Leicester Cough Questionnaire (LCQ), and we judged the quality of the evidence to be low using the GRADE approach. Data were reported as between-group difference from baseline to four weeks (MD 1.53, 95% confidence interval (CI) 0.21 to 2.85; participants = 71), revealing a statistically significant benefit for people receiving a physiotherapy and speech and language therapy intervention (PSALTI) versus control. However, the difference between PSALTI and control was not observed between week four and three months. The same study provided information on SAEs, and there were no SAEs in either the PSALTI or control arms. Using the GRADE approach we judged the quality of evidence for this outcome to be low.Data were also available for our prespecified secondary outcomes. In each case data were provided by only one study, therefore there were no opportunities for aggregation; we judged the quality of this evidence to be low for each outcome. A significant difference favouring therapy was demonstrated for: objective cough counts (ratio for mean coughs per hour on treatment was 59% (95% CI 37% to 95%) relative to control; participants = 71); symptom score (MD 9.80, 95% CI 4.50 to 15.10; participants = 87); and clinical improvement as defined by trialists (OR 48.13, 95% CI 13.53 to 171.25; participants = 87). There was no significant difference between therapy and control regarding subjective measures of cough (MD on visual analogue scale of cough severity: -9.72, 95% CI -20.80 to 1.36; participants = 71) and cough reflex sensitivity (capsaicin concentration to induce five coughs: 1.11 (95% CI 0.80 to 1.54; participants = 49) times higher on treatment than on control). One study reported data on adverse events, and there were no adverse events reported in either the therapy or control arms of the study. AUTHORS' CONCLUSIONS The paucity of data in this review highlights the need for more controlled trial data examining the efficacy of SLT interventions in the management of UCC. Although a large number of studies were found in the initial search as per protocol, we could include only two studies in the review. In addition, this review highlights that endpoints vary between published studies.The improvements in HRQoL (LCQ) and reduction in 24-hour cough frequency seen with the PSALTI intervention were statistically significant but short-lived, with the between-group difference lasting up to four weeks only. Further studies are required to replicate these findings and to investigate the effects of SLT interventions over time. It is clear that SLT interventions vary between studies. Further research is needed to understand which aspects of SLT interventions are most effective in reducing cough (both objective cough frequency and subjective measures of cough) and improving HRQoL. We consider these endpoints to be clinically important. It is also important for future studies to report information on adverse events.Because of the paucity of data, we can draw no robust conclusions regarding the efficacy of SLT interventions for improving outcomes in unexplained chronic cough. Our review identifies the need for further high-quality research, with comparable endpoints to inform robust conclusions.
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Affiliation(s)
- Claire Slinger
- Lancashire Teaching Hospitals TrustDepartment of Respiratory MedicinePrestonUK
| | - Syed B Mehdi
- Lancashire Teaching Hospitals TrustDepartment of Respiratory MedicinePrestonUK
| | | | - Steven Dodd
- Lancaster UniversityFaculty of Health and MedicineLancasterUK
| | - Jessica Matthews
- Lancashire Teaching Hospitals TrustDepartment of Respiratory MedicinePrestonUK
| | - Aashish Vyas
- Lancashire Teaching Hospitals TrustDepartment of Respiratory MedicinePrestonUK
| | - Paul A Marsden
- Lancashire Teaching Hospitals TrustDepartment of Respiratory MedicinePrestonUK
- Wythenshawe Hospital, Manchester University NHS Foundation TrustNorth West Lung CentreManchesterUK
- School of Biological Sciences, University of ManchesterDivision of Infection, Immunity and Respiratory MedicineManchesterUK
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17
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Famokunwa B, Walsted ES, Hull JH. Assessing laryngeal function and hypersensitivity. Pulm Pharmacol Ther 2019; 56:108-115. [PMID: 31004747 DOI: 10.1016/j.pupt.2019.04.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/13/2019] [Accepted: 04/17/2019] [Indexed: 10/27/2022]
Abstract
The larynx is one of the most highly innervated organs in humans, adapted to simultaneously deliver several key respiratory functions including airway protection, swallowing and phonation. In some individuals the larynx can adopt a state that could be considered 'dysfunctional' or maladaptive; resulting in or contributing to a range of clinical disorders such as chronic refractory cough, inducible laryngeal obstruction (previously termed paradoxical vocal fold movement or vocal cord dysfunction), muscle tension dysphonia and globus pharyngeus. These disorders appear to display significant overlap in clinical symptomology and in many cases have features of concomitant or allied sensory dysfunction; often described as laryngeal hypersensitivity. The recognition and accurate assessment of both laryngeal dysfunction±hypersensitivity is important to ensure accurate diagnosis and effective delivery of targeted treatment and therapeutic monitoring. Accordingly, there is increasing in the methodologies proposed to assess laryngeal function. These range from simple questionnaires to targeted investigation(s), assessing both sensory function and the laryngeal motor response, under both resting and provoked situations. This review provides a brief overview of the current state of knowledge in the field of laryngeal dysfunction and hypersensitivity assessment.
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Affiliation(s)
- B Famokunwa
- Bristol Royal Infirmary, Bristol, BS2 8HW, UK
| | - E S Walsted
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark; Department of Respiratory Medicine, Royal Brompton Hospital, London, SW3 6HP, UK
| | - J H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, SW3 6HP, UK.
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18
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Hull JH, Walsted ES, Orton CM, Williams P, Ward S, Pavitt MJ. Feasibility of portable continuous laryngoscopy during exercise testing. ERJ Open Res 2019; 5:00219-2018. [PMID: 30740460 PMCID: PMC6360209 DOI: 10.1183/23120541.00219-2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 12/08/2018] [Indexed: 01/19/2023] Open
Abstract
Exercise-induced laryngeal obstruction (EILO) is a prevalent and yet still under-recognised cause of exertional breathlessness [1]. The transient closure of the larynx, which develops during EILO, results in dyspnoea, cough, inspiratory wheeze (i.e. stridor) and tightness in the throat on physical exertion. It is estimated that EILO is present in 6% of adolescents and as many as one in four athletes with unexplained respiratory symptoms [1, 2]. Despite improved recognition over the past 5 years [3, 4], it remains frequently misdiagnosed and mistreated as asthma [2, 5]. Exercise-induced laryngeal obstruction (EILO) is a prevalent problem causing exertional breathlessness and wheeze. This report demonstrates the feasibility and safety of a diagnostic approach to EILO, using a portable laryngoscope during exercise.http://ow.ly/eM6L30njDst
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Affiliation(s)
- James H Hull
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Emil S Walsted
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK.,Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Parris Williams
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Simon Ward
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Mathew J Pavitt
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
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19
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Olin JT. Exercise-Induced Laryngeal Obstruction: When Pediatric Exertional Dyspnea Does not Respond to Bronchodilators. Front Pediatr 2019; 7:52. [PMID: 30881950 PMCID: PMC6405419 DOI: 10.3389/fped.2019.00052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/07/2019] [Indexed: 12/03/2022] Open
Abstract
Exertional dyspnea is a common complaint in general pediatric practice. While a high proportion of the general pediatric population has asthma, other diagnoses, including exercise-induced laryngeal obstruction should be considered, especially when asthma therapy is not sufficient to control symptoms. This review describes some of the key clinical features of exercised-induced laryngeal obstruction as well as preferred diagnostic and therapeutic approaches. Importantly, current diagnostic technology has considerably improved in the last decade at specialty centers. At the same time, infrastructure for clinical trials is emerging and there is not strong evidence to support specific therapies at the current time.
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Affiliation(s)
- J Tod Olin
- Department of Pediatrics, National Jewish Health, Denver, CO, United States
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20
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Hull JH, Walsted ES, Feary J, Cullinan P, Scadding G, Bailey E, Selby J. Continuous laryngoscopy during provocation in the assessment of inducible laryngeal obstruction. Laryngoscope 2018; 129:1863-1866. [DOI: 10.1002/lary.27620] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/15/2018] [Accepted: 09/24/2018] [Indexed: 11/08/2022]
Affiliation(s)
- James Harry Hull
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
| | - Emil Schwarz Walsted
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
- Respiratory Research Unit, Bispebjerg University Hospital; Copenhagen Denmark
| | - Johanna Feary
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
- Department of Occupational and Environmental Medicine; Royal Brompton Hospital; London United Kingdom
| | - Paul Cullinan
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
- Department of Occupational and Environmental Medicine; Royal Brompton Hospital; London United Kingdom
| | - Guy Scadding
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
| | - Emma Bailey
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
| | - Julia Selby
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
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Slinger C, Mehdi SB, Milan SJ, Dodd S, Blakemore J, Vyas A, Marsden PA. Speech and language therapy for management of chronic cough. Hippokratia 2018. [DOI: 10.1002/14651858.cd013067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Claire Slinger
- Lancashire Teaching Hospitals Trust; Department of Respiratory Medicine; Preston UK
| | - Syed B Mehdi
- Lancashire Teaching Hospitals Trust; Department of Respiratory Medicine; Preston UK
| | | | - Steven Dodd
- Lancaster University; Faculty of Health and Medicine; Lancaster UK
| | - Jessica Blakemore
- Lancashire Teaching Hospitals Trust; Department of Respiratory Medicine; Preston UK
| | - Aashish Vyas
- Lancashire Teaching Hospitals Trust; Department of Respiratory Medicine; Preston UK
| | - Paul A Marsden
- Lancashire Teaching Hospitals Trust; Department of Respiratory Medicine; Preston UK
- Lancaster University; Faculty of Health and Medicine; Lancaster UK
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22
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Clinical presentation, assessment, and management of inducible laryngeal obstruction. Curr Opin Otolaryngol Head Neck Surg 2018. [DOI: 10.1097/moo.0000000000000452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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23
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The Future of Exertional Respiratory Problems: What Do We Know About the Total Airway Approach and What Do We Need to Know? Immunol Allergy Clin North Am 2018; 38:333-339. [PMID: 29631741 DOI: 10.1016/j.iac.2018.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Exercise is increasingly viewed as a preventative and therapeutic modality for medical and behavioral health disorders. Therefore, it is imperative that the medical and scientific communities minimize barriers that discourage exercise. This issue of Immunology and Allergy Clinics of North America details a "total airway approach" to the evaluation of exertional respiratory problems. Reviews guide clinicians through evaluation and therapy. Moving forward, there is much room for growth with respect to research in each of these areas as well as for common inflammatory pathways and neurophysiologic coupling across all airway segments.
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Olin JT, Hull JH. Exercise and the Total Airway: A Call to Action. Immunol Allergy Clin North Am 2018; 38:xv-xix. [PMID: 29631744 DOI: 10.1016/j.iac.2018.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- J Tod Olin
- Pediatric Exercise Tolerance Center, Department of Pediatrics, Division of Pediatric Pulmonology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.
| | - James H Hull
- Royal Brompton Hospital, Imperial College, Department of Respiratory Medicine, Royal Brompton Hospital, Fulham Road, London SW3 6HP, UK.
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Graham S, Deardorff E, Johnston K, Olin JT. The Fortuitous Discovery of the Olin EILOBI Breathing Techniques: A Case Study. J Voice 2017; 32:695-697. [PMID: 29050660 DOI: 10.1016/j.jvoice.2017.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/13/2017] [Accepted: 08/18/2017] [Indexed: 10/18/2022]
Abstract
Exercise-induced laryngeal obstruction (EILO) is the term for the condition previously named vocal cord dysfunction and paradoxical vocal fold motion. It is defined by glottic or supraglottic obstruction during periods of intense exercise. Not all patients respond to conventional therapy with speech-language pathology, behavioral health interventions, and treatment of contributing conditions. In this edition of Journal of Voice, the authors describe a novel series of respiratory retraining techniques, now called Olin EILOBI (EILO biphasic inspiratory) breathing techniques, specifically designed for athletes with EILO. This case presentation describes the discovery of one of these techniques during a session of therapeutic laryngoscopy during exercise. The patient was an adolescent with EILO who demonstrated a positive response to therapy with a variant of these techniques over a few days, having previously struggled with symptoms despite multiple sessions of conventional respiratory retraining over the course of months.
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Affiliation(s)
- Sarah Graham
- Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - Emily Deardorff
- Department of Rehabilitation Medicine, National Jewish Health, Denver, Colorado
| | - Kristina Johnston
- Department of Rehabilitation Medicine, National Jewish Health, Denver, Colorado
| | - J Tod Olin
- Department of Pediatrics, National Jewish Health, Denver, Colorado.
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26
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Bey A, Botti S, Coutier-Marie L, Bonabel C, Metche S, Demoulin-Alexikova S, Schweitzer CE, Marchal F, Coffinet L, Ioan I. Bronchial or Laryngeal Obstruction Induced by Exercise? Front Pediatr 2017; 5:150. [PMID: 28702452 PMCID: PMC5487400 DOI: 10.3389/fped.2017.00150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/15/2017] [Indexed: 11/13/2022] Open
Abstract
A child suspected of exercise-induced laryngeal obstruction and asthma is examined by laryngoscopy and respiratory resistance (Rrs) after exercise challenge. Immediately at exercise cessation, the visualized adduction of the larynx in inspiration is reflected in a paroxystic increase in Rrs. While normal breathing has apparently resumed later on during recovery from exercise, the pattern of Rrs in inspiration is observed to reoccur following a deep breath or swallowing. The procedure may thus help diagnosing the site of exercise-induced obstruction when laryngoscopy is not available and identify re-inducers of laryngeal dysfunction.
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Affiliation(s)
- Ayoub Bey
- Service d'ORL pédiatrique, Hôpital d'enfants, CHRU de Nancy, Vandoeuvre, France
| | - Sophie Botti
- Service d'ORL pédiatrique, Hôpital d'enfants, CHRU de Nancy, Vandoeuvre, France
| | - Laurianne Coutier-Marie
- Service d'explorations fonctionnelles pédiatriques, Hôpital d'enfants, CHRU de Nancy, Vandoeuvre, France
| | - Claude Bonabel
- Service d'explorations fonctionnelles pédiatriques, Hôpital d'enfants, CHRU de Nancy, Vandoeuvre, France.,DevAH EA 3450, Faculté de Médecine, Université de Lorraine, Vandoeuvre, France
| | - Stéphanie Metche
- Service d'explorations fonctionnelles pédiatriques, Hôpital d'enfants, CHRU de Nancy, Vandoeuvre, France
| | - Silvia Demoulin-Alexikova
- Service d'explorations fonctionnelles pédiatriques, Hôpital d'enfants, CHRU de Nancy, Vandoeuvre, France.,DevAH EA 3450, Faculté de Médecine, Université de Lorraine, Vandoeuvre, France
| | - Cyril Etienne Schweitzer
- Service d'explorations fonctionnelles pédiatriques, Hôpital d'enfants, CHRU de Nancy, Vandoeuvre, France.,DevAH EA 3450, Faculté de Médecine, Université de Lorraine, Vandoeuvre, France.,Service de Pédiatrie, Hôpital d'enfants, CHRU de Nancy, Vandoeuvre, France
| | - François Marchal
- Service d'explorations fonctionnelles pédiatriques, Hôpital d'enfants, CHRU de Nancy, Vandoeuvre, France.,DevAH EA 3450, Faculté de Médecine, Université de Lorraine, Vandoeuvre, France
| | - Laurent Coffinet
- Service d'ORL pédiatrique, Hôpital d'enfants, CHRU de Nancy, Vandoeuvre, France
| | - Iulia Ioan
- Service d'explorations fonctionnelles pédiatriques, Hôpital d'enfants, CHRU de Nancy, Vandoeuvre, France.,DevAH EA 3450, Faculté de Médecine, Université de Lorraine, Vandoeuvre, France
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