Laryngocele and epiglottic cyst as rare causes of obstructive sleep apnea

Arytenoid Cartilage Collapse During Inhalation in Awake Patients with Intermediate/High Risk of Obstructive Sleep Apnea: A Retrospective Analysis of Sixty-Four Patients

OBJECTIVE

To assess the prevalence of arytenoid cartilage collapse (ACC) during deep inhalation in awake patients with intermediate/high risk of obstructive sleep apnea (OSA).

STUDY DESIGN

Retrospective case-control study.

METHODS

The medical records and video recordings of awake flexible endoscopic examination of patients with history of OSA who presented to the sleep apnea clinic in a tertiary referral medical center between June 2022 and December 2022, were reviewed. All patients had filled the STOP-BANG questionnaire and had intermediate/high risk of having OSA. A group of patients matched by age and gender and with no history of OSA were used as controls.

RESULTS

A total of 95 patients, 64 with a history of OSA and 31 with no history of OSA, were included. Among the study group, 37.5% (n = 24) had a STOP-BANG score between 3 and 4 and were considered to be at an intermediate risk of OSA while the remaining had a score more than 5 and were considered to be at high risk of OSA. There was a significant difference in the prevalence of ACC between the study group and controls (32.8% vs 12.9%, respectively, P < 0.001).

CONCLUSION

The prevalence of ACC was significantly higher in patients with intermediate/high risk of OSA in comparison to healthy controls with no history of OSA. When present, ACC should raise the physician's suspicion for OSA and probably prompt further investigation such as a sleep study.

An Uncommon Epiglottic Cyst Presentation in an Adolescent: A Case Report and Literature Review

Epiglottic cysts are benign lesions of the larynx that are relatively rare beyond infancy age. A 17-year-old adolescent male patient presented to the outpatient specialized oropharyngeal clinic with inspiratory stridor, chronic sore throat, and progressive dyspnea symptoms over the past eight months. Examination by a headlight and a tongue depressor showed a large cystic lesion arising from the hypopharynx. A neck computed tomography (CT) scan revealed a 4 cm oval cyst attached to the lingual epiglottic surface. The relatively large epiglottic cyst was drained directly in the clinic and was later removed by microlaryngosurgery with traditional microinstrumentation in a follow-up visit. Subsequent recovery was uneventful. Regardless of the rarity of epiglottic cysts in adolescents, doctors should keep in mind this etiology as early diagnosis and management could spare the patient from life-threatening complications or tracheostomy and unneeded medical costs.

Scoping review of head and neck neoplasms presenting with obstructive sleep apnoea: the importance of flexible nasendoscopy

BACKGROUND

Obstructive sleep apnoea (OSA) can be caused by neoplasms involving the upper aerodigestive tract. Currently, many of these patients have this diagnosis missed, as most adults diagnosed with OSA do not undergo adequate head and neck examination including flexible nasendoscopy. We performed a review of the literature to shed light on this phenomenon and outline the pathologies and issues surrounding this sub-population of patients diagnosed with OSA.

METHODS

A scoping review of the literature was conducted on head and neck neoplasms presenting with OSA. Data were extracted on demographics, clinical presentation, histopathology, treatment and patient outcomes.

RESULTS

Sixty-seven articles were included, describing 79 patients. Mean age was 45.8 years, and 77.2% were male. Symptoms of OSA were present for an average of 29.2 months before a diagnosis of causative neoplasm was made. Forty-two different benign and malignant histopathological entities were reported. At diagnosis, the causative pathology of 100% of patients was visible on head and neck examination including flexible nasendoscopy, while only 53.2% were visible on trans-oral examination. One-third of patients had commenced inappropriate treatment for OSA, including three who had undergone sleep surgical procedures. The majority of patients were treated with surgery alone (72.2%).

CONCLUSION

Although rare, neoplasms of the upper aerodigestive tract should be considered as a cause of OSA, especially in patients experiencing other symptoms in addition to the typical symptoms of OSA. They should particularly be considered in patients with comparatively lower body mass index or those with worsening OSA without an apparent cause identified.

The association of OSAS and uvula: the role of MRI in this egg-chicken problem in OSAS

PURPOSE

Obstructive sleep apnea syndrome (OSAS) is a condition resulting from repetitive partial or complete upper airway obstruction, and its etiology remains uncertain. Polysomnography is the gold standard diagnostic test for OSAS. However, there are long wait times for this evaluation, so questionnaires or ancillary diagnostic methods are used to select appropriate patients. One of these is magnetic resonance imaging (MRI). The present study aimed to investigate the association between clinical features of OSAS and uvular changes on MRI.

MATERIALS AND METHODS

A total of 102 participants, 80 with OSAS and 22 controls, were included in the study. All participants underwent full-night polysomnography, MRI, and anthropometric measurements.

RESULTS

In comparisons of MRI measurements of the uvula, statistically significant differences in uvular length, thickness, and angle were observed between the OSAS and control groups. MRI measurement significantly associated with apnea-hypopnea index was uvular thickness. Evaluation of anthropometric and MRI measurements revealed statistically significant associations between waist circumference and uvular thickness, uvular width, and oropharyngeal space among the OSAS patients.

CONCLUSION

Thickened uvula on MRI is associated with the presence of OSAS, and its thickness is well correlated with the severity of the diseases. Thus, it may be a reliable indicator of OSAS and could be used as a supportive finding to identify patients suitable for referral for diagnostic polysomnography.

The effect of unilateral forced nostril breathing on sleep in healthy right-handed men: a preliminary report

PURPOSE

Although we spend about one-third of our lives in sleep and recognize its necessity for good health, sleep has only been partially elucidated in the last century. The nasal cycle of congestion and decongestion during sleep has various effects on human physiology. The aim of the present study was to investigate the effect of unilateral forced nostril breathing on sleep.

METHODS

Twenty-one healthy male volunteers aged 18-24 years were included in the study. Only individuals with right-hand dominance were included. Subjects were observed during sleep for three nights under different conditions: no obstruction (normal sleep) on the first night, right nasal obstruction on the second night, and left nasal obstruction on the third night.

RESULTS

The main findings of our study are that sleep efficiency, NREM stage III, and total sleep duration were greater during left nasal obstruction (right nostril dominant respiration), while apnea-hypopnea index (AHI), frequency of periodic limb movements, and oxygen desaturation were higher during right nasal obstruction (left nostril dominant respiration).

CONCLUSION

The nasal cycle has a significant impact on sleep which is reflected in sleep recordings. Our result supports that nasal obstructions, due to deviations, concha hypertrophy, or congestion/decongestion, might affect the physiology of respiration and sleep. Nasal obstruction should be taken into consideration when evaluating patients in sleep laboratories and further studies are required to elucidate the situation in the patients with nasal obstruction.

Laryngeal Cysts in Adults: Simplifying Classification and Management

Objective

Laryngeal cysts may occur at any mucosa-lined location within the larynx and account for 5% to 10% of nonmalignant laryngeal lesions. A number of proposed classifications for laryngeal cysts exist; however, no previously published classification aims to guide management. This review analyzes contemporary laryngeal cyst management and proposes a framework for the terminology and management of cystic lesions in the larynx.

Data Sources

PubMed/Medline.

Review Methods

A primary literature search of the entire Medline database was performed for all titles of publications pertaining to laryngeal cysts and reviewed for relevance. Full manuscripts were reviewed per the relevance of their titles and abstracts, and selection into this review was according to their clinical and scientific relevance.

Conclusion

Laryngeal cysts have been associated with rapid-onset epiglottitis, dyspnea, stridor, and death; therefore, they should not be considered of little significance. Symptoms are varied and nonspecific. Laryngoscopy is the primary initial diagnostic tool. Cross-sectional imaging may be required, and future use of endolaryngeal ultrasound and optical coherence tomography may revolutionize practice. Where possible, cysts should be completely excised, and there is growing evidence that a transoral approach is superior to transcervical excision for nearly all cysts. Histology provides definitive diagnosis, and oncocytic cysts require close follow-up.

Implications for Practice

A new classification system is proposed that increases clarity in terminology, with the aim of better preparing surgeons and authors for future advances in the understanding and management of laryngeal cysts.

Bilateral combined laryngocele

Laryngocele is an uncommon condition that represents a benign dilatation of the laryngeal saccule with air and/or fluid, arising in the region of the laryngeal ventricle. Laryngoceles, or laryngomucocele can be classified as internal, or combined. The aim of presenting this rare case of a bilateral combined laryngocele, are to emphasize the importance of diagnostic laryngoscopy in upper airway pathologies evaluation, increase awareness in the general otolaryngologist community, and to highlight the external surgical method.

Airway Management of Incidental Vallecular Cysts in Adults

Vallecular cysts, largely asymptomatic in adults, are typically described only on incidental discovery during laryngoscopy, where they may present a challenge in airway management. The current literature is limited to case reports despite the potential for life-threatening complications. We describe management of such a case complicated by cyst rupture and intensive care unit admission. A literature review of eligible case reports was conducted, demonstrating an association between incidental vallecular cysts and difficult bag-mask ventilation and laryngoscopy with intraoperative otolaryngology consultation and intervention being common. Anesthetic management recommendations are thus presented, highlighting any conflicts with current difficult airway algorithms.

Treatment of Laryngoceles: what is the progress over the last two decades?

OBJECTIVES

To review surgical techniques used in the treatment of laryngoceles over the last two decades and point out developments and trends.

MATERIALS AND METHODS

PubMed, the Cochrane Library, and the JBI Library of Systematic Reviews were searched using the term "laryngocele." Demographic data, type of laryngocele, presence of a laryngopyocele, type of treatment and need for a tracheotomy were assessed.

RESULTS

Overall, data on 86 patients were analyzed, culled from 50 articles, of which 41 were case reports and 9 were case series. No single systematic review or meta-analysis or randomized controlled trial has been published on the topic. Altogether, 71 laryngoceles in 63 patients met the criteria for further analysis focusing on surgical treatment. An external approach was selected in 25/29 (86.2%) cases of combined laryngoceles. Microlaryngoscopic resection using a CO2 laser was performed in three cases and endoscopic robotic surgery in one case. The majority of patients with an internal laryngocele, 31/42 (73.8%), were treated using the microlaryngoscopy approach.

CONCLUSIONS

Microlaryngoscopy involving the use of a CO2 laser has become the main therapeutic procedure for the treatment of internal laryngoceles during the past 20 years. An external approach still remains the main therapeutic approach for the treatment of combined laryngoceles.