Solitary Bone Plasmacytoma of the Skull Base With an Unusual Presentation

Solitary bone plasmacytoma (SBP) is a rare hematological malignancy that usually occurs in the spine and rarely in the skull. It rarely presents in the skull base, but presenting symptoms are associated with cranial nerve involvement depending on the site of the disease. We present the case of a 61-year-old man with an unusual presentation of hoarseness secondary to vocal fold palsy. Imaging showed a large bony lesion in the temporo-occipital region with involvement of the jugular foramen. Further detailed diagnostic procedures confirmed SBP of the skull base. Radiotherapy was given with an uneventful recovery of vocal fold function. Skull base plasmacytoma can be considered as a differential diagnosis of causes of unilateral vocal fold palsy. Early therapeutic management may improve vocal fold function.

The Effect of Topical Benzydamine Hydrochloride and Cuff Pressure Monitorization on Postoperative Sore Throat Due to Intubation

OBJECTIVE

Postoperative sore throat (POST) is the most common discomfort after endotracheal intubation. Damage to the tracheal mucosa caused by inappropriate endotracheal tube (ETT) cuff pressure has been shown as the major factor. Monitoring the ETT cuff pressure at a certain value reduces this damage. Benzydamine hydrochloride (BH) has proven to be effective on sore throat and studies have shown that it is also effective on POST. In this study, the efficacy of BH and ETT cuff pressure monitoring on POST was evaluated.

MATERIALS AND METHODS

After ethics committee approval 210 patients in the ASA (American Society of Anesthesiologists) I-III risk group undergoing elective surgery were included in the study. Routine anesthesia monitoring, induction, and maintenance were provided. Patients were randomly divided into three groups. Thirty minutes before surgery, the posterior pharyngeal wall was sprayed with BH in group 1 and distilled water in groups 2 and 3. Intraoperatively, the first and second groups were monitored to keep the ETT cuff pressure between 22 and 26 cmH2O, while no intervention was performed in the third group. The incidence and severity of postoperative dysphagia, hoarseness, and POST were questioned.

RESULTS

There was no difference between demographic data, and gender was not associated with POST. There was a statistically significant difference between the first and second groups and the third group in terms of all three symptoms questioned (p<0.01). No difference was observed between the first and second groups. Side effect rates were similar. Smoking was not found to be associated with symptoms.

CONCLUSION

The incidence and severity of POST, dysphagia, and hoarseness are reduced when the ETT cuff is inflated with a pressure of 22-26 cmH2O after intubation with a manometer and maintained at this pressure range throughout the operation. There was no beneficial effect of BH.

Voice Disorders Among Teachers in Taif City, Kingdom of Saudi Arabia

Background Voice disorders (VD) pose significant challenges for teachers as they impact their professional and personal lives. Teaching requires extensive use of the voice, making teachers particularly susceptible to vocal health issues. VD can hinder the quality of education. Objectives This study aimed to comprehensively explore the prevalence, associated factors, and impact of VD among teachers and their health-seeking behavior regarding VD. Methodology A cross-sectional observational study was conducted in Taif City, Kingdom of Saudi Arabia (KSA), between November and December 2023. The data were collected through a questionnaire covering demographic variables, occupational factors, voice-related symptoms, associated health conditions, and the impact of VD. The statistical analysis was performed using SPSS Statistics version 26 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.), and chi-squared tests were used to assess associations. Results The study involved 568 teachers, 61.8% of whom had VD. The study identified significant associations between VD and demographic characteristics, habits, and teaching-related variables. Age, gender, teaching subject, class size, and weekly teaching load were associated with the prevalence of VD. Hoarseness, throat pain, and throat dryness were prevalent symptoms among teachers with VD. The impact of VD on teachers was evident, with a considerable proportion reporting work absenteeism (28.7%) and even contemplating retirement due to voice problems (6.3%). Conclusion This study offers a nuanced understanding of VD among teachers in the Taif region, emphasizing the complex interplay of demographic, symptomatic, and behavioral factors. The findings underscore the need for targeted interventions, including awareness campaigns, preventive strategies, and streamlined healthcare access, to address the unique challenges that different subgroups of teachers face. Future research should further explore longitudinal trajectories and objective measures to enhance our understanding of VD in educational settings.

Laryngeal Mycosis in an Immunocompetent Patient: A Case Report

Laryngeal mycosis, a condition often overlooked in systemically immunocompetent individuals, requires heightened clinical vigilance for accurate diagnosis. The disease mimics symptoms of other laryngeal conditions such as gastroesophageal reflux, granulomatous disease, keratosis, and glottic malignancies, with risk factors including prolonged use of antibiotics, inhaled steroids, and smoking. Clinically, it presents with variable symptoms including hoarseness, and occasionally pain, dysphagia, and odynophagia. Diagnosis involves the observation of hyperkeratosis, notably when intraepithelial neutrophils are present, prompting further investigation for fungal elements through specialized staining. Effective management encompasses prolonged systemic antifungal treatment and the elimination of predisposing factors to prevent recurrence or treatment failure. Despite its potential to mimic a range of laryngeal diseases, laryngeal mycosis remains a less considered differential diagnosis. This is compounded by the commonality of risk factors in the general population, including prolonged antibiotic use, inhaled steroid therapy, and smoking habits, which may predispose individuals to fungal infections of the larynx. Furthermore, the necessity for a high index of suspicion and specialized diagnostic techniques, such as the identification of hyperkeratosis with intraepithelial neutrophils through biopsy and specialized staining for fungal elements, underscores the complexity of diagnosing this condition. The rationale for documenting this case report is multifaceted, primarily focusing on the fact that laryngeal mycosis is rare among immunocompetent patients leading to under-recognition of laryngeal mycosis in systemically immunocompetent individuals and the diagnostic challenges it presents. Additionally, the documentation seeks to emphasize the critical need for comprehensive treatment approaches, including prolonged systemic antifungal therapy and the identification and elimination of predisposing factors, to ensure effective management and prevent recurrence.

Exploring Skull Base Osteomyelitis: Comprehensive Case Reports and Management Strategies

Skull base osteomyelitis is a not commonly encountered but potentially fatal consequence of untreated necrotizing otitis externa. Early recognition and appropriate treatment are crucial to prevent serious complications such as cranial nerve palsies, meningitis, and intracranial abscess formation. The case reports presented in this study provide a rich depiction of the clinical presentation, diagnostic challenges, and interventions employed. Early recognition and appropriate management of skull base osteomyelitis are crucial to prevent complications and improve patient outcomes.

Preemptive strategies and lessons learned from complications encountered with microvascular decompression for hemifacial spasm

OBJECTIVE

Microvascular decompression (MVD) is the only curative treatment modality for hemifacial spasm (HFS). Although generally considered to be safe, this surgical procedure is surrounded by many risks and possible complications. The authors present the spectrum of complications that they met in their case series, the possible causes, and the strategies recommended to minimize them.

METHODS

The authors reviewed a prospectively maintained database for MVDs performed from 2005 until 2021 and extracted relevant data including patient demographics, offending vessel(s), operative technique, outcome, and different complications. Descriptive statistics with uni- and multivariable analyses for the factors that may influence the seventh, eighth, and lower cranial nerves were performed.

RESULTS

Data from 420 patients were obtained. Three hundred seventeen of 344 patients (92.2%) with a minimum follow-up of 12 months had a favorable outcome. The mean follow-up (standard deviation) was 51.3 ± 38.7 months. Immediate complications reached 18.8% (79/420). Complications persisted in only 7.14% of patients (30/420) including persistent hearing deficits (5.95%) and residual facial palsy (0.95%). Temporary complications included CSF leakage (3.10%), lower cranial nerve deficits (3.57%), meningitis (0.71%), and brainstem ischemia (0.24%). One patient died because of herpes encephalitis. Statistical analyses showed that the immediate postoperative disappearance of spasms and male gender are correlated with postoperative facial palsy, whereas combined vessel compressions involving the vertebral artery (VA) and anterior inferior cerebellar artery can predict postoperative hearing deterioration. VA compressions could predict postoperative lower cranial nerve deficits.

CONCLUSIONS

MVD is safe and effective for treating HFS with a low rate of permanent morbidity. Proper patient positioning, sharp arachnoid dissection, and endoscopic visualization under facial and auditory neurophysiological monitoring are the key points to minimize the rate of complications in MVD for HFS.

A Plasmacytoma of the Lateral Pharyngeal Wall: A Diagnostic Enigma

Plasmacytoma is a rare plasma cell dyscrasia that grows in bones or soft tissues such as the pharynx. Soft tissue plasmacytomas are rare, and a higher burden has been reported in the upper aero-digestive tract, often manifesting as hoarseness, dysphagia, or odynophagia. Due to their rarity, extramedullary plasmacytomas (EMPs) have unknown prognostic factors, and guidelines for optimal management are still lacking. However, radiation therapy and surgery have been used with positive outcomes. Herein, we describe a unique case of plasmacytoma of the pharyngeal tissue in a male patient with a history of HIV disease. The patient completed 28 sessions of radiation therapy, resulting in an improvement in his throat pain and hoarseness. Given the patient's age and lack of traditional risk factors for head and neck cancers, his hoarseness and odynophagia proved to be a diagnostic conundrum. Although infrequent, soft tissue plasmacytomas should be considered in the differential diagnosis of head and neck tumors.

Validation of the Acoustic Breathiness Index in Speakers of Finnish Language

Breathiness (perception of turbulence noise in the voice) is one of the major components of hoarseness in dysphonic voices. This study aims to validate a multiparameter analysis tool, the Acoustic Breathiness Index (ABI), for quantification of breathiness in the speaking voice, including both sustained vowels and continuous speech. One hundred and eight speakers with dysphonia (28 M, 80 F, mean age 50, SD 15.4 years) and 87 non-dysphonic controls (18 M, 69 F, mean age 42, SD 14 years) volunteered as participants. They read a standard text and sustained vowel /a:/. Acoustic recordings were made using a head-mounted microphone. Acoustic samples were evaluated perceptually by nine voice experts of different backgrounds (speech therapists, vocologists and laryngologists). Breathiness (B) from the GRBAS scale was rated. Headphones were used in the perceptual analysis. The dysphonic and non-dysphonic speakers differed significantly from each other in the auditory perceptual evaluation of breathiness. A significant difference was also found for ABI, which had a mean value of 2.26 (SD 1.15) for non-dysphonic and 3.07 (SD 1.75) for dysphonic speakers. ABI correlated strongly with B (rs = 0.823, p = 0.01). ABI's power to distinguish the groups was high (88.6%). The highest sensitivity and specificity of ABI (80%) was obtained at threshold value 2.68. ABI is a valid tool for differentiating breathiness in non-dysphonic and dysphonic speakers of Finnish.

The impact of a speaker's voice quality on auditory perception and cognition: a behavioral and subjective approach

Introduction

Our voice is key for conveying information and knowledge to others during verbal communication. However, those who heavily depend on their voice, such as teachers and university professors, often develop voice problems, signaled by hoarseness. The aim of this study was to investigate the effect of hoarseness on listeners' memory for auditory-verbal information, listening effort, and listening impression.

Methods

Forty-eight normally hearing adults performed two memory tasks that were auditorily presented in varied voice quality (typical vs. hoarse). The tasks were Heard Text Recall, as part of a dual-task paradigm, and auditory Verbal Serial Recall (aVSR). Participants also completed a listening impression questionnaire for both voice qualities. Behavioral measures of memory for auditory-verbal information and listening effort were performance and response time. Subjective measures of listening effort and other aspects of listening impression were questionnaire rating scores.

Results

Results showed that, except for the aVSR, behavioral outcomes did not vary with the speaker's voice quality. Regarding the aVSR, we found a significant interaction between voice quality and trial, indicating that participants' recall performance dropped in the beginning of the task in the hoarse-voice condition but not in the typical-voice condition, and then increased again toward the end. Results from the listening impression questionnaire showed that listening to the hoarse voice resulted in significantly increased perceived listening effort, greater annoyance and poorer self-reported performance.

Discussion

These findings suggest that hoarseness can, at least subjectively, compromise effective listening. Vocal health may be particularly important in the educational context, where listening and learning are closely linked.

Pediatric Dysphonia: When to Refer

The reported prevalence of voice disorders in the pediatric population varies widely between studies, ranging from 3.9% to 23%. Despite this, not all children with dysphonia are referred to a voice specialist for further evaluation. The objective of this study is to examine the relationship between dysphonia history, voice assessment, and laryngeal findings to help guide referrals of dysphonic children. A retrospective review was conducted of pediatric patients at a tertiary voice clinic between January 2014 and December 2017. Data including dates of presentation, demographics, co-morbidities, presenting symptoms, laryngeal exam findings, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores, and Pediatric Voice Handicap Index (pVHI) scores were collected and analyzed. Of 475 patients initially identified, 459 met inclusion criteria and were reviewed. In all, 272 (59.3%) were male and 187 (40.7%) were female. Mean age at first presentation was 8.6 years old (range: 2-18). Males were more likely to present at a younger age than females. CAPE-V data were available for 439 patients, and pVHI data were available for 109 patients. The mean CAPE-V Overall Severity score was 38.2. The mean total pVHI score was 25.4. Males had higher CAPE-V Overall Severity (40.0 vs. 35.4), Roughness (32.2 vs. 27.6), and Strain scores (37.2 vs. 32.4) than females. Patient pVHI scores did not differ by gender. In all, 283 patients self-reported a length of symptoms prior to evaluation. Children with a longer duration of symptoms prior to evaluation had higher CAPE-V Overall Severity scores. Diagnoses of vocal fold movement impairment and benign vocal fold lesions that were not nodules were associated with higher average CAPE-V Overall Severity scores. Overall, 310 patients (67.5%) were recommended intervention for their dysphonia. These patients had higher CAPE-V Overall Severity scores than those who were solely recommended observation (42.8 vs. 28.0). Males were more likely than females to present with dysphonia and presented with more severe perceptual dysphonia scores on average. The length of symptoms and certain diagnoses correlated with higher CAPE-V Scores. Referrals to a pediatric voice clinic should be considered in patients with a dysphonia history lasting greater than 3 months and in patients with more severe symptoms.

Pediatric Laryngeal Granular Cell Tumor: Case Report and Literature Review

Granular cell tumors (GCTs) are rare benign tumors that can occur in any part of the body. They are most commonly found in the head and neck region, especially the tongue. Laryngeal GCTs are rare, accounting for only 3% to 10% of all GCTs. This case report describes a 4-year-old boy with a laryngeal GCT. The patient presented with a history of hoarseness for 2 years. Stroboscopy revealed a large mass occupying the entire length of the left vocal cord. The mass was successfully removed by microlaryngeal surgery with laser ablation. The patient's symptoms resolved after surgery, and he had an uneventful recovery. This case highlights the importance of considering GCTs in the differential diagnosis of patients with hoarseness. Early diagnosis and treatment can lead to excellent outcomes.

Intraoperative Neuromonitoring Does Not Reduce the Risk of Temporary and Definitive Recurrent Laryngeal Nerve Damage during Thyroid Surgery: A Systematic Review and Meta-Analysis of Endoscopic Findings from 73,325 Nerves at Risk

BACKGROUND

While intraoperative neuromonitoring (IONM) helps the early identification of recurrent laryngeal nerve (RLN) damage, IONM's role in RLN damage prevention is not defined, given the lack of large studies on the subject.

METHODS

In a PRISMA-compliant framework, all original thyroid surgery prospective studies providing early postoperative endoscopic data for all patients were pooled in a random-effects meta-analysis. We compared the temporary (and definitive where available) RLN damage rates according to IONM use and IONM type (intermittent, I-IONM, or continuous, C-IONM).

RESULTS

We identified 2358 temporary and 257 definitive RLN injuries in, respectively, 73,325 and 66,476 nerves at risk. The pooled temporary and definitive RLN injury rates were, respectively, 3.15% and 0.422% considering all procedures, 3.29% and 0.409% in cases using IONM, and 3.16% and 0.463 in cases not using IONM. I-IONM and C-IONM, respectively, showed a pooled temporary RLN injury rate of 2.48% and 2.913% and a pooled definitive injury rate of 0.395% and 0.4%. All pooled rates had largely overlapping 95% confidence intervals.

CONCLUSIONS

Our data suggest that IONM does not affect the temporary or definitive RLN injury rate following thyroidectomy, though its use can be advised in selected cases and for bilateral palsy prevention.

Effects of Endotracheal Tube with Adhesive Superficial Laryngeal Electrodes for Intraoperative Nerve Monitoring on Laryngopharyngeal Complications during Thyroidectomy

The endotracheal tube (ETT) with laryngeal adhesive electrodes for intraoperative neural monitoring (IONM) may be related to laryngopharyngeal complications, such as postoperative sore throat (POST), hoarseness, and coughing. We aimed to evaluate the effects of the ETT with laryngeal adhesive electrodes for IONM on the occurrence of laryngopharyngeal complications during thyroidectomy. In this retrospective study, we included 176 patients who underwent thyroidectomy for thyroid cancer between September 2020 and February 2021. The patients were categorized into control (n = 108) and IONM (n = 68) groups. Patients in the IONM group were intubated with the ETT with surface electrodes. Characteristics of the patients and surgery, perioperative variables, and laryngopharyngeal complications, including POST, hoarseness, and cough, were evaluated. The severity and incidence of POST were comparable between the two groups on postoperative days 0, 1, and 2 (p = 0.103, 0.386, and 0.056, respectively). Furthermore, no significant differences were observed in the occurrence of postoperative hoarseness and cough between the groups. The ETT with laryngeal adhesive electrodes for IONM during thyroidectomy did not affect the incidence and severity of postoperative laryngopharyngeal complications, including POST, hoarseness, and cough. Further prospective, double-blinded, randomized clinical trials are required to gain a clearer understanding.

Distal Arch Aneurysm Discovered With Dysphagia

A 64-year-old man sought medical attention from a family physician, expressing concerns about dysphagia. Recognizing the complexity of the symptoms, the family physician promptly engaged the expertise of an attending physician at a regional hospital to ensure accurate diagnosis and management. Plain computed tomography (CT) revealed a space-occupied lesion located posterior to the trachea. Although mediastinal tumor was suspected at first, contrast-enhanced CT revealed a distal arch aneurysm that compressed the esophagus. The patient underwent total arch replacement, and the postoperative course was uneventful.

Ortner's syndrome: A systematic review of presentation, diagnosis and management

Ortner's syndrome (OS), also called cardiovocal syndrome, is a rare condition hallmarked by left recurrent laryngeal nerve palsy due to underlying cardiopulmonary disease. The purpose of this review is to systemically analyze the existing literature for cases of OS to outline typical presentation, methods of diagnosis, and management of these patients. Case reports, case series, and cohort studies describing OS between 1955 and 2021 were identified. Individual manuscripts were reviewed for clinical features, presentation, and management. A total of 117 patient cases were gathered from 92 published articles. Common symptoms included hoarseness, dyspnea, cough, and dysphagia. The most common associated comorbidity was aortic aneurysm (41%), followed by pulmonary hypertension (35%), mitral stenosis (17%), and hypertension (12%). Among those who were managed via surgical intervention, 85.4% reported improvement in their hoarseness. While historically OS was associated with mitral stenosis, in recent decades, aortic aneurysms and dilation of the pulmonary artery from pulmonary hypertension have emerged as primary etiologies of OS. Therefore, OS should be considered in any patient presenting with hoarseness and history of cardiopulmonary disease. Surgical intervention in appropriate candidates resolves OS in most cases.

Advances in Clinical Voice Quality Analysis with VOXplot

BACKGROUND

The assessment of voice quality can be evaluated perceptually with standard clinical practice, also including acoustic evaluation of digital voice recordings to validate and further interpret perceptual judgments. The goal of the present study was to determine the strongest acoustic voice quality parameters for perceived hoarseness and breathiness when analyzing the sustained vowel [a:] using a new clinical acoustic tool, the VOXplot software.

METHODS

A total of 218 voice samples of individuals with and without voice disorders were applied to perceptual and acoustic analyses. Overall, 13 single acoustic parameters were included to determine validity aspects in relation to perceptions of hoarseness and breathiness.

RESULTS

Four single acoustic measures could be clearly associated with perceptions of hoarseness or breathiness. For hoarseness, the harmonics-to-noise ratio (HNR) and pitch perturbation quotient with a smoothing factor of five periods (PPQ5), and, for breathiness, the smoothed cepstral peak prominence (CPPS) and the glottal-to-noise excitation ratio (GNE) were shown to be highly valid, with a significant difference being demonstrated for each of the other perceptual voice quality aspects.

CONCLUSIONS

Two acoustic measures, the HNR and the PPQ5, were both strongly associated with perceptions of hoarseness and were able to discriminate hoarseness from breathiness with good confidence. Two other acoustic measures, the CPPS and the GNE, were both strongly associated with perceptions of breathiness and were able to discriminate breathiness from hoarseness with good confidence.

Intraoperative Measurement of Endotracheal Tube Cuff Pressure and Its Change During Surgery in Correlation With Recurrent Laryngeal Nerve Palsies, Hoarseness, and Dysphagia After Anterior Cervical Discectomy and Fusion: A Prospective Randomized Controlled Trial

STUDY DESIGN

Prospective randomized controlled trial.

OBJECTIVES

Adjustment of endotracheal tube cuff pressure (ETCP) in anterior cervical discectomy and fusion (ACDF) may influence the incidence of complications such as recurrent laryngeal nerve palsy (RLNP), hoarseness, and dysphagia.

METHODS

The prospective randomized controlled trial was designed to investigate the influence of ETCP on the incidence of postoperative complications. All eligible patients underwent vocal cord examination before and after ACDF and were randomized into a control group (CG) and intervention group (IG). Endotracheal tube cuff pressure was passively monitored in CG, and in IG, it was maintained at 20 mmHg. Outcomes were evaluated during hospitalization and during follow-up.

RESULTS

A total of 98 patients were randomized, each group consisted of 49 patients. Statistical analysis showed that gender and age did not influence the incidence of complications. In CG, duration of retractor placement and extent of approach significantly impacted the occurrence of complications. The incidence of postoperative RLNP was 8.2% in IG and 12.2% in CG, hoarseness and dysphonia were present in 18.4% in IG and in 37.5% in CG, and dysphagia in 20.8% in IG and in 22.5% in CG. Hoarseness was significantly present more in CG (P = .018). Only one patient from CG presented with RLNP after 1 year, the remaining nine patients spontaneously recovered.

CONCLUSIONS

Unregulated ETCP can lead to a significantly higher incidence of hoarseness; however, its improvement rate is 100%. The early postoperative complication rate was higher in CG, and after one year, 1 patient had RLNP and 1 patient had dysphagia.

Audiological, Phonatory and Cardiac Correlates of Individuals Exposed to Low-Frequency Noise or at Risk of Vibroacoustic Disease

Introduction  Low-frequency noise (LFN) is hazardous to hearing. Long-term exposure to LFN may lead to vibroacoustic disease (VAD), which not only affects a specific organ but the physiological function of entire systems, such as the auditory, phonatory, respiratory, and cardiac systems. Moreover, VAD may lead to many psychological problems and hence affect the quality of life. Objective  To investigate the adverse effects of LFN on hearing, acoustic and perceptual correlates of the voice, blood pressure, cardiac rate, and anxiety level. Method  A total of 20 subjects exposed to LFN and 20 not exposed to LFN were included, and a detailed case history was recorded. The patients were submitted to pure tone audiometry, otoscopic examination, acoustic and perceptual analyses of the voice, maximum phonation time, and an assessment of the s/z ratio. We also assessed blood pressure, and the results of a voice-related quality of life questionnaire and of the Hamilton anxiety rating scale. Results  The results indicate that LFN had an adverse impact on the high-frequency threshold. The present study found a significant difference in shimmer and harmonics-to-noise ratio (HNR) values. Few subjects had high blood pressure and showed the sign of anxiety on the Hamilton anxiety rating scale. Conclusion  Low-frequency noise has adverse effects on entire systems of the body and causes many psychological issues, which, in turn negatively affect quality of life.

Does Baska mask deserve its own niche among extraglottic airway devices? A prospective, single-arm study

Background and Aims

A variety of extraglottic airway devices (EADs) are available. Main concerns with EADs are protection against aspiration and ability to ventilate patients with high airway pressures. Baska mask meets these criteria and is the only third-generation device available for clinical use.

Methods

After institutional ethics committee approval and informed consent were obtained, this prospective study was performed in 100 adult patients undergoing surface surgeries at a tertiary referral centre. The primary outcome was the success rate of insertion, while the secondary outcomes were the sealing pressure, stability of the device and the perioperative complications of Baska mask. We then compared it with other currently used EADs.

Results

The first attempt at insertion and overall success rates, showed values of 81% and 98%, respectively. Insertion was quick (median 12; interquartile range [IQR] 9-15 s). The mask sealing pressure, was 35 cmH2O (median [IQR 20-50 cmH2O]). Also, the mask remained stable in 95% of patients intraoperatively. Sore throat and dysphagia were seen in 37% and 24% of patients, respectively. No patient had laryngospasm or desaturation at any time. It compared favourably well with other EADs, while achieving higher sealing pressures.

Conclusion

We found that the Baska mask performs well with excellent first attempt at insertion and overall success rates, higher sealing pressures and minimal complications compared to currently used EADs in clinical anaesthesia.

Unilateral False Cord Nodule Presenting As Hoarseness in a Young Patient

Vocal cord nodules are benign laryngeal lesions seen in professional voice users. They are usually bilateral and are thought to occur due to submucosal edema and hemorrhage, with resultant fibrosis. False cord occurrences are very rare; hence we report a unique case of unilateral right false cord nodule. A healthy 16-year-old female student presented with persistent hoarseness for two years without any history of voice abuse, trauma, infection, or endotracheal intubation. Endoscopic examination showed a mass occupying the right false cord. Subsequent direct laryngoscopy revealed a friable mass on the right false cord without any true cord involvement. Complete excision was done. Post-operatively her symptoms completely resolved, and flexible endoscopic examination seven months post-op showed no recurrence. Histopathological examination revealed fragments of fibro collagenous tissue covered by benign respiratory epithelium, favoring the diagnosis of a benign nodule. False cord benign lesions are rare. In a symptomatic case, endolaryngeal microsurgery gives a good outcome.

Hoarseness as the initial presentation of multiple myeloma

Key Clinical Message

Myeloma of the thyroid cartilage is a rare but important differential diagnosis of a laryngeal mass. Although hoarseness as the initial presenting symptom in multiple myeloma is extremely rare, a clinician should always consider it.

Abstract

Multiple myeloma (MM) is a malignant plasma cell disorder characterized by an uncontrolled proliferation of monoclonal plasma cells. Although the clinical presentation at diagnosis can be quite variable, thyroid cartilage infiltration in MM is rare. Here we discuss a 65-year-old Caucasian male presenting to the ENT doctor with continuous hoarseness for 3 months. The initial clinical examination showed a tangible mass at the left lymph node level II-III. Further examination with fiber-optic laryngoscopy showed a bulging of the aryepiglottic and ventricular fold. Neck and chest CT scan revealed multiple osteolytic bone lesions in addition to the large lesion in the left thyroid cartilage. Laboratory work-up, PET-CT scan and biopsy of the thyroid cartilage were performed and eventually all confirmed the presence of a new diagnosis of IgA kappa MM. The patient was referred to the department of hematology to start with chemotherapy.

The prevalence and risk factors of hoarseness among pupils in elementary schools in the South of Finland

Purpose: Hoarseness and voice problems are one of the chronic conditions experienced by children. The aim of this study was to investigate the prevalence of hoarseness, possible risk factors and effects of the remediation of school buildings to the prevalence of hoarseness among school children.Methods: The material was gathered from all the schools in a large city in the south of Finland and the collection method used was an e-mail survey sent to the parents of the pupils and a simultaneous survey sent to the personnel in the schools.Results: All 51 schools participated, and 5889 pupils returned the questionnaire (39%). The exposure data was obtained from two building experts who knew the repair history of the schools. A subjective estimation of the quality of the indoor air was obtained from teachers and the parents. The overall prevalence of hoarseness among pupils was 6.3%; prevalence being higher in unrepaired school buildings than in schools in a good condition or buildings with a thorough remediation. Hoarseness was associated with asthma and allergies, several respiratory symptoms, and respiratory infections. Exposure to tobacco smoke increased the risk, and consumption of caffeine containing drinks seemed to reduce the risk. Noise, stuffiness of the indoor air and microbial smells correlated strongly with the occurrence of hoarseness in a logistic regression model when controlled for age, gender, asthma, passive smoking, and caffeine consumption.Conclusions: We recommend renovations in school buildings with the aim of providing better acoustics, sufficient ventilation, and a reduction in exposure to moisture damage microbes.

A comparison of two methods of lymph node dissection along the left recurrent laryngeal nerve in McKeown minimally invasive esophagectomy

Background

Lymph nodes dissection in esophagectomy is an essential procedure for radical resection, which can not only provide more accurate staging but may also improve survival, while it is technically challenging and may lead to recurrent laryngeal nerve (RLN) paralysis. Numerous efforts have been directed to achieve the dissection of more LNs around the RLN and to lower the incidence of RLN palsy, including Bascule method and modified Bascule method. On this basis, we modified and applied a novel method which involves the en bloc dissection of lymph nodes dissection along the left RLN in McKeown minimally invasive esophagectomy (MIE).

Methods

A total of 244 consecutive cases of lymphadenectomy along the left RLN during McKeown MIE at our institution between January 2018 and August 2021 were retrospectively analyzed. The cases were divided into two groups based on the methods of lymphadenectomy along the left RLN: 77 cases received the conventional method (CM group) and 167 cases received the novel method (NM group). The surgical outcomes, especially the impact of surgical proficiency on the outcomes of lymphadenectomy along the left RLN, were assessed and compared between the two groups.

Results

Demographic data of the two cohorts were similar. The number of harvested lymph nodes (LNs) (total/abdomen/left RLN) in the NM group was markedly higher than that in the CM group (32 vs. 27, P=0.006; 11 vs. 9, P=0.038; 3 vs. 2, P=0.044). However, the number of harvested LNs from the chest or right RLN was not significantly different in the two groups. The hoarseness rate was 1.8% in the NM group, which was slightly but not notably lower than that of the CM group (1.8% vs. 2.6%, P=0.681). The incidence of LN metastasis along the left RLN was 13.9%, 15.6%, and 13.2% in the whole cohort, CM group, and NM group, respectively.

Conclusions

Our novel method not only increased the number of LN dissections along left RLN but also slightly reduced the incidence of hoarseness. Therefore, this novel method of lymphadenectomy along the left RLN during McKeown MIE is safe and reliable.

The Clinical Impact of Vagal Nerve Stimulator Implantation on Laryngopharyngeal Function in Children: A Single-Center Experience

OBJECTIVE

A vagal nerve stimulator (VNS) has been established as the treatment of choice for children with refractory epilepsy. The outcomes of the procedure have been well documented in adults but are less clear in children. The goal of our study was to review laryngopharyngeal (LP) function following VNS implantation in children.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary-care children's hospital.

METHODS

Voice, swallowing, and sleep apnea symptoms were extracted from the charts of children who underwent VNS implantation between 2013 and 2021. A questionnaire was sent to parents of implanted children to ascertain the degree of the social and functional impact of the implant.

RESULTS

There were 69 patients, aged 2.3 to 21.4 years old, who met the inclusion criteria. LP symptoms were most common during the first year following implantation; 26 patients (37.6%) demonstrated at least 1 symptom (voice alteration, chronic cough, sleep-disordered breathing, or dysphagia), and 15 patients required adjustments to their implant settings. The incidence of symptoms and the need to adjust VNS settings significantly dropped during years 2 to 5 and 6 to 8 (22% vs 7% and 5%, respectively, p = .0002). The mean score of the Pediatric Voice Handicap Index differed greatly from a normal control group on each subscale and the total score.

CONCLUSION

LP dysfunction in children following VNS implantation is comparable to adults, with the most burden noticed during the first year after implantation. The presence of voice alterations did not correlate with the presence of dysphagia and sleep-disordered breathing. Thorough evaluation, preferably by a multidisciplinary team, is required to assess LP dysfunction postoperatively.

A Randomized Comparison of Effects of Budesonide Spray and K-Y Gel as an Endotracheal Tube Cuff Lubricant on Incidence of Postoperative Sore Throat

PURPOSE

Postoperative sore throat (POST) is a frequent postoperative complication. Pre-induction budesonide inhalation is effective in POST prevention. However, it requires inhaler equipment and patient cooperation. Budesonide spraying on the endotracheal (ETT) cuff is simple and can be performed on most patients requiring endotracheal intubation. This study aims to compare the effects of budesonide spray and K-Y gel as an ETT cuff lubricant on the incidence and severity of POST.

DESIGN

Randomized and triple-blinded study.

METHODS

One hundred patients undergoing elective non-cardiac surgery were randomly allocated into the budesonide group (n = 50) and the K-Y gel group (n = 50). In the budesonide group, 200 mcg of budesonide was sprayed on the cuff of the ETT. For the K-Y gel group, the ETT cuff was lubricated with K-Y gel. A visual analog scale was used to assess the severity of POST at 2, 6, and 24 hours after surgery. Other complications of tracheal intubation and adverse effects of budesonide were also recorded.

FINDINGS

Compared to the K-Y gel group, the budesonide group had a significantly lower overall incidence of POST (30% versus 54%, P = .032) and reduced the risk of POST by 24% (relative risk reduction = 24%, 95% CI, 5.23-42.77, P = .012) as well as the incidence of hoarseness (8.6% vs 34%, P = .001) and cough (0% vs 8%, P = 0.041). No incidence of drug-related side effects was reported in both groups.

CONCLUSIONS

Spraying budesonide on the ETT cuff significantly reduces the incidence and severity of POST.

Supraglottic Foreign Body Missed for One Month in a Child

Foreign body (FB) aspiration in children can result in serious complications that can lead to even death. We present a case of a one-year-old girl child with a history of choking one month prior while she was feeding. A bolus of rice was removed at a local clinic. Consequently, within 24 hours, she developed hoarseness and noisy breathing which was treated as an upper respiratory tract infection at two different clinics. This case report aims to highlight the need for otolaryngology consultation in a child with non-resolving respiratory symptoms following episodes of choking. This will prompt an immediate surgical intervention that could prevent potential morbidity and mortality as a result of a compromised airway.

Ortner syndrome caused by aberrant right subclavian artery: A case report

INTRODUCTION

Ortner syndrome (cardiovocal hoarseness) is characterized by recurrent laryngeal nerve paralysis secondary to a cardiovascular abnormality. Ortner syndrome caused by an aberrant right subclavian artery following a retroesophageal course without aneurysm formation is rare, with only 1 case reported in the literature. Cardiovascular abnormalities could be life-threatening and require early diagnosis and treatment. However, such abnormalities are not often considered by clinical practitioners when patients initially present with hoarseness.

PATIENT CONCERNS

A 34-year-old woman without any medical history presented to our outpatient department with hoarseness and mild dysphagia for 1 month.

DIAGNOSIS

Upon stroboscopic examination, left vocal cord incomplete paralysis was noted. Contrast-enhanced computed tomography revealed an aberrant right subclavian artery arising from the left aortic arch, causing focal compression of the esophagus and, potentially, compression of the left recurrent laryngeal nerve compression. The patient was diagnosed as left recurrent laryngeal nerve paralysis caused by an aberrant right subclavian artery following a retroesophageal course without aneurysm formation.

INTERVENTIONS

The patient was referred to a cardiovascular surgeon for resection and bypass surgery. Both the dysphagia and the hoarseness improved after the surgery.

OUTCOMES

Significant improvement of the left vocal cord paralysis and no vocal cord adduction were seen upon stroboscopic examination after 3 months. During the 5-year follow-up period, the patient remained well, and no signs of recurrence were noted.

CONCLUSION

This case can increase otolaryngologists' awareness of this etiology of hoarseness and consider it in their differential diagnosis.

A Case of Non-cutaneous Kaposi Sarcoma

Kaposi sarcoma is a malignancy common in patients with acquired immune deficiency syndrome (AIDS). It is a proliferative soft-tissue tumor commonly manifesting as pigmented papules and nodules on the skin. Lesions can also appear on the mucosal lining of the oropharynx and other parts of the body such as the lymph nodes. Head and neck involvement in Kaposi sarcoma is not unusual; however, laryngeal involvement is not commonly seen. We report the case of a 31-year-old gentleman, a former smoker with AIDS, who developed a mass in the throat with progressive hoarseness of voice without stridor. An elective tracheostomy was done to protect his airway before performing a direct laryngoscopy with biopsy. Histopathology examination showed neoplastic spindle cells positive for CD31, erythroblast transformation specific-related gene, and human herpesvirus 8, consistent with Kaposi sarcoma. The diagnosis of laryngeal Kaposi sarcoma in immunodeficient patients requires a high index of suspicion, especially when it occurs without classical dermatological manifestation, an interesting feature in this report.

[Clinical characteristics of 1330 elderly patients with voice diseases diagnosed by electronic laryngoscope]

Objective:To investigate the clinical features of electronic laryngoscope in the diagnosis of senile voice diseases. Methods:Elderly patients who visited the outpatient department of Otolaryngology Head and Neck Surgery, Nanjing Drum Tower Hospital from September 2014 to September 2018 were collected. All patients came in with hoarseness. All patients were routinely diagnosed by electronic laryngoscopy and the results were analyzed. Results:A total of 1330 elderly patients aged 60 years and over were enrolled in this study, including 924 males and 406 females. There are significant differences in the distribution of various voice diseases in different genders（P<0.05）. Among male elderly patients, the top three were: 239 cases of throat malignant tumor（25.87%）, 182 cases of vocal cord benign proliferative disease（19.70%）, 147 cases of vocal cord leukoplakia（15.91%）. Among female elderly patients, the top three diseases were: 183 cases（45.07%） of vocal cord benign proliferative disease, 70 cases（17.24%） of laryngitis, 66 cases（16.26%） of vocal cord paralysis. There were significant differences in the distribution of different voice disorders among the three different age groups of elderly patients. The top three elderly patients aged 60-69 years were: 298 cases（35.06%） of vocal cord benign proliferative diseases, 132 cases（15.53%） of laryngopharyngeal malignant tumors, 104 cases（12.24%） of vocal cord paralysis. The top three elderly patients aged 70-79 years were: 91 cases（24.20%） of laryngopharyngeal malignant tumors, 57 cases（15.16%） of vocal cord benign proliferative diseases, 55 cases（14.63%） of vocal cord paralysis. The top three elderly patients aged 80 years and above were: 25 cases（24.04%） of laryngopharyngeal malignant tumors, 21 cases（20.19%） of vocal cord paralysis, 16 cases（15.38%） of the vocal cords are not closed completely. There were also significant differences in the distribution of various voice diseases among smokers（P<0.05）. Conclusion:With the acceleration of the aging of society, we should pay more attention to the voice of the elderly. The most common disease in elderly women with hoarseness is benign hyperplastic vocal cord disease. The high incidence of laryngeal malignant tumors in elderly male hoarseness patients who smoke should be paid special attention to. Electronic laryngoscope plays an important role in the diagnosis of voice diseases in elderly patients.

The Role of the Otolaryngologist in Early Recognition of Patients With ALS: A Case Report

This case report aims to raise awareness of the possibility of amyotrophic lateral sclerosis (ALS) diagnosis in patients presenting to the Otolaryngology Department. We describe the case of a 66-year-old woman with hoarseness who was evaluated by several physicians and was referred to an ALS specialist only a year after symptom onset. Our case highlights the importance of considering motor neuron etiologies in patients with voice complaints. Early identification and referral to a specialist are critical for accurate diagnosis and prognosis and may be the key to slowing the disease's progression.

The Comparison of Inflation of Cuff with 1% Propofol, 4% Lignocaine, or 0.9% Saline on Laryngotracheal Morbidity

Background and Aim

While administering general anesthesia requiring endotracheal intubation, it is a common practice to inflate the cuff with air. Continuous pressure exerted by cuff on mucosa may lead to postoperative complaints such as sore throat, cough, and dysphagia, which are very disturbing to the patient. Hence, we hypothesized that inflation of cuff with propofol may reduce the incidence of these complications as a result of cushioning effect as well as non-diffusion of nitrous oxide into it. Our aim was to compare the effects of inflation of endotracheal tube cuff with 0.9% saline, 4% lignocaine, and 1% propofol on the incidence of postoperative morbidity in terms of cough, sore throat, dysphonia, and dysphagia with general anesthesia using nitrous oxide.

Methods

Patients scheduled for elective surgery under general anesthesia were randomly allocated into four equal groups of thirty each as per cuff inflation media: air (Group A), 0.9% saline (Group S), 4% lidocaine (Group L), and 1% propofol (Group P). The incidence of cough was noted at 15, 30 and 60 min after extubating. The occurrence and severity of postoperative sore throat (POST) was evaluated at 2, 6, and 24 h after extubating.

Results

The incidence of cough was maximum in Group A and minimum in Group P (P < 0.05). The occurrence of POST was highest in Group A, followed by Group S and Group L, and least in Group P. The hemodynamic parameters were comparable with no statistical difference in all the four groups (P < 0.05).

Conclusion

The intracuff 1% propofol is superior to 4% xylocaine and normal saline in the prevention of cough and sore throat postoperatively, whereas inflation of cuff with air leads to maximum incidence of these complications.

Recurrent Laryngeal Nerve Injury in Thermal Ablation of Thyroid Nodules-Risk Factors and Cause Analysis

CONTEXT

Recurrent laryngeal nerve (RLN) injury is a complication of thermal thyroid nodule treatment.

OBJECTIVE

We investigated the influencing factors of RLN injury in patients who underwent thermal ablation of thyroid nodules.

METHODS

The data of 1004 patients (252 male, 752 female; median age 44 years) who underwent thermal thyroid nodule ablation were retrospectively reviewed. Patients were divided into benign cystic, benign solid, and papillary thyroid cancer (PTC) groups. The parameters related to RLN injury were analyzed, including the largest diameter, location of the nodules, and shortest distance of the nodule to thyroid capsule and tracheoesophageal groove (TEG). Univariate and multivariate analyses were performed to select risk factors for RLN injury.

RESULTS

The RLN injury rate was higher in PTC (6.3%) than in benign cystic (1.2%, P = 0.019) and solid nodules (2.9%, P = 0.018). PTC subgroup analysis showed that the RLN injury rate was higher in T1b (10.7%) and T2 (28.6%) PTC than in T1a PTC (5.0%, P < 0.05). In the PTC group, TEG distance, anterior capsule distance, median capsule distance, posterior capsule distance, and maximum nodule diameter were risk factors for RLN injury. The logistic regression fitting of the nomogram showed high prediction efficiency (C-Index 0.876). The main cause of RLN injury was insufficient medial isolating fluid (MIF). The safety thicknesses of MIF for benign cystic, benign solid, and PTC nodules were 3.1 mm, 3.7 mm, and 3.9 mm, respectively.

CONCLUSION

Several risk factors for RLN injury should be considered before thermal ablation of thyroid nodules. The RLN injury rate could be predicted with the nomogram.

Treatment Options and Voice Outcomes for Patients With Unilateral Vocal Fold Paralysis After Thyroidectomy

Objectives

This study investigated the treatment options and clinical outcomes of voice therapy (VT), hyaluronic acid (HA) injection, autologous fat injection (FI), and medialization thyroplasty (MT) in patients with unilateral vocal fold paralysis (UVFP) after thyroidectomy.

Study Design

Retrospective case series.

Setting

A tertiary teaching hospital.

Methods

This study included 51 patients with post-thyroidectomy UVFP who underwent VT (n = 20), HA injection (n = 14), FI (n = 12), or MT (n = 5) from January 2016 to June 2021. The treatment outcomes were evaluated using 10-item voice handicap index (VHI-10), maximal phonation time (MPT), and auditory perceptual rating using GRB scales (i.e., grade, roughness, and breathiness) before and 3 to 6 months after treatment.

Results

Patients received HA injection presented a significantly shorter interval after thyroidectomy (mean: 4.6 months), followed by VT (6.7 months), FI (12.3 months), and MT (22.4 months). The results exhibited improvement in most of the outcomes after all of the four treatments. Additional comparisons indicated that VHI-10 scores improved the most among patients receiving MT, followed by HA, FI, and VT. The differences of MPT and GRB scores among the 4 treatment groups were non-significant.

Conclusions

The results revealed that VT, HA, FI, and MT can all improve the voice outcomes of patients with post-thyroidectomy UVFP. The optimal treatment approach should be individualized according to the patient's preference and vocal demand, and the interval between thyroidectomy and intervention.

Prevalence and Determinants of Hoarseness in School-Aged Children

Hoarseness in school-aged children may affect their educational achievement and interfere with their communication and social skills development. The global prevalence of hoarseness in school-aged children ranges between 6% and 23%. To the best of our knowledge, there is a scarcity of studies describing the prevalence or determinates of hoarseness in Saudi school-aged children. Our aim was to measure the prevalence of hoarseness among school-aged children and to identify its determinants. A cross-sectional questionnaire-based survey was used that included randomly selected primary and early childhood schools from private and governmental sectors in Saudi Arabia. The data were collected using a questionnaire which was self-completed by the children's parents and covered the following aspects: sociodemographic features, health and its related comorbidities about children and their families, attendance and performance in school, child's voice tone, past history of frequent crying during infancy, history of letter pronunciation problems and stuttering, the Reflux Symptom Index (RSI) and the Children's Voice Handicap Index-10 for parents (CVHI-10-P). Determinants of hoarseness were investigated using the SPSS software (version 20). The mean age of the study children (n = 428) was 9.05 years (SD = 2.15), and 69.40% of them were male. The rate of hoarseness in the participants was 7.5%. Hoarseness was significantly common in children with a history of excessive infancy crying (p = 0.006), letter pronunciation issues (especially 'R' and 'S'; p = 0.003), and stuttering (p = 0.004) and in those with a previous history of hoarseness (p = 0.023). In addition, having the symptoms of gastrointestinal reflux increased the risk of hoarseness by four times (OR = 4.77, 95% CI = 2.171, 10.51). In summary, hoarseness in children may be dangerously underestimated, as it may reflect the presence of speech problems, in addition to the presence of laryngopharyngeal reflux (LPR). Hoarseness was assumed on the basis of parental complaints. Therefore, further research with diagnoses based on a clinical assessment is needed to understand the magnitude of the hoarseness problem and its consequences in children.

Penetrating foreign body in the larynx presenting as hoarseness

Penetrating neck injuries are not uncommon, while penetrated foreign bodies involving the larynx are rare, which can be critical and challenging even for experienced physicians. We presented a case of a 64-year-old man with a piece of grinder blade penetrating through the subglottic region, visiting our outpatient department with hoarseness persisting for 3 weeks. The flexible fiberoptic laryngoscope, CT and direct laryngoscope were used to establish the right diagnosis. A cervical incision over the prior scar region was performed to remove the foreign body from the laryngeal box. Clinically, laryngotracheal injuries could lead to severe crisis without proper and prompt treatment. As to penetrated foreign bodies involving the larynx, a proper airway management and surgical approach are crucial for minimizing the morbidity and mortality. An accurate localization and preoperative planning is on the other hand indispensable to a successful removal and recovery.

Laryngeal schwannoma: A case report and literature review

Laryngeal schwannomas are rare benign neurogenic tumors of the larynx. They cannot be detected in the early stages because disease onset is asymptomatic. This case of laryngeal schwannoma provided a reference for clinical diagnosis and treatment strategy. A 24-year-old man presented with a 3-year history of hoarseness and sore throat for 6 months. Laryngoscopy and computed tomography showed submucosal bulging of the right ventricular fold in the right paraglottic space. The patient underwent tracheotomy first, followed by laryngotomy. The edema of the laryngeal mucosa was significantly alleviated, with normal movement of the bilateral vocal cords on the 10th day after surgery. The tracheal tube was removed at the time of discharge. The hoarseness had disappeared at the end of the first month after surgery. The effective treatment of laryngeal schwannoma involves complete resection with surgery while protecting the integrity of the larynx and restoring laryngeal function. The indication for surgery should be strictly controlled to avoid damage to the mucosa and structures of the larynx.

Comparison between I-gel® and endotracheal intubation in terms of the incidence of postoperative sore throat following thyroid surgery: a randomized observational trial

BACKGROUND

Postoperative sore throat (POST) is a common complication following thyroid surgery with an endotracheal tube (ET). The I-gel^® is a supraglottic airway device that has greater advantages in airway management compared with ET. This prospective trial aimed to explore the potential benefits of I-gel^® compared with ET on POST.

METHODS

In this trial, 106 patients, classified using the American Society of Anesthesiologists (ASA) physical status classification system, belonging to classes I and II, aged 18-65 years old who were prearranged for elective radical thyroidectomy, were randomly divided into the ET and I-gel^® groups. All patients underwent total intravenous anesthesia (propofol, sufentanil, and cisatracurium). The incidence and severity of POST and postoperative hoarseness (PH) at 1, 6, 24, and 48 h following the operation were assessed and compared between the two groups. Moreover, the hemodynamic data during anesthesia were recorded and compared. Opioid consumption (sufentanil, propofol, and remifentanil) and postoperative nausea and vomiting were recorded. The visual analog scale scores for pain at the incision site 1, 6, 24, and 48 h postoperatively and Ramsay Sedation Scale scores were also evaluated and recorded.

RESULTS

No significant difference was observed in the incidence of POST 1, 6, 24, and 48 h postoperatively (61.2% vs. 51.0%, P=0.309; 75.5% vs. 83.7%, P=0.316; 83.7% vs. 85.7%, P=0.779; and 12.2% vs. 22.4%, P=0.182, respectively) and the severity of sore throat (P=0.392) following surgery between the ET and I-gel^® groups. The incidence of PH in the I-gel^® group was significantly lower than that in the ET group 1, 6, 24, and 48 h postoperatively (all P<0.05). Compared with the ET group, a significantly less fluctuation in heart rate 1 min after intubation (P=0.045) and extubation (P=0.001) was observed in the I-gel^® group.

CONCLUSIONS

Although the I-gel^® cannot reduce the incidence and severity of POST in patients with normal BMIs following thyroid surgery, it can reduce the occurrence and severity of PH compared with ET. The I-gel^® showed superior results in terms of insertion time and better hemodynamic condition during intubation.

[Results of a prospective observational study of the effectiveness of the complex drug Homeovox in adult patients with various types of dysphonia]

The voice as the most important means of communication is of great importance in a person's life. Every year the number of specialties for which voice and speech are a key tool of professional activity increases. Diseases of the vocal apparatus reduce the ability to work, and for some people pose a threat of professional unfitness. The relevance of the study is determined not only by the significant prevalence of dysphonia, but also by the insufficient effectiveness of existing methods of treating voice disorders.

OBJECTIVE

To evaluate the clinical efficacy and safety of the use of the drug Homeovox in patients with acute and chronic catarrhal laryngitis as monotherapy. To fulfill the set goal of the study, the following tasks were solved: evaluation of the clinical effectiveness of the drug Homeovox as monotherapy for various types of dysphonia; evaluation of the effectiveness of the drug Homeovox as monotherapy from the 1st day of use.

MATERIAL AND METHODS

The basis for the implementation of the tasks was the analysis of the results of the examination and treatment of 60 patients with voice disorders aged 18 to 75 years. Among them, 10 (17%) patients with acute laryngitis and 50 (83%) patients with chronic laryngitis. To establish the diagnosis, a comprehensive examination was carried out, involving examination, videolaryngostroboscopy, acoustic analysis of the voice. The study design included three patient visits, during which the functional state of the vocal apparatus was examined by subjective and objective methods.

RESULTS

As a result of the treatment with the use of the drug Homeovox, the efficacy and safety of this drug in the treatment of dysphonia in adult patients with acute and chronic laryngitis from the first days of therapy has been proven, which is confirmed by the method of videolaryngostroboscopy and acoustic analysis of the voice.

CONCLUSION

The drug Homeovox is an effective, safe remedy and can be included in the complex treatment of laryngeal pathology in order to increase its effectiveness and achieve a therapeutic effect in a shorter time, manifested by an improvement in the clinical and functional state of larynx.

Case Report: A Rare Cause of Stridor and Hoarseness in Infants-Congenital Laryngeal Web

BACKGROUND

Congenital laryngeal web is a rare disease that can cause stridor, dyspnea, hoarseness, and other symptoms. Children with this disease generally have stridor, weak crying, and hoarseness at birth, but these symptoms can also occur during the days, weeks, months, and even years after birth. Respiratory tract infection will obviously aggravate these manifestations, and recovery is slow after symptomatic treatment. Neck CT and laryngoscopy can detect and diagnose this disease. It is important that the disease can be considered and examined in infants with recurrent stridor and persistent hoarseness after birth.

CASE SUMMARY

We report a 23-month-old boy who was admitted to hospital due to stridor and hoarseness after birth. Combined with the results of laryngoscopy, he was diagnosed with congenital laryngeal web, and was treated with carbon dioxide (CO₂) laser and cryotherapy by bronchoscope. The prognosis was good.

CONCLUSION

Congenital laryngeal web is a rare but challenging laryngeal lesion. It is very important that the disease can be considered and examined for infants with recurrent stridor and persistent hoarseness after birth. The treatment strategy after diagnosis should be determined according to the classification of laryngeal web and the severity of children's symptoms.

Carcinoma Showing Thymus-like Differentiation (CASTLE) with Synchronous Papillary Thyroid Carcinoma: A Case Report and Review

Carcinoma showing thymus-like differentiation (CASTLE) is a rare malignant tumor that accounts for 0.1%-0.15% of all thyroid cancers. More than half of the patients have tumor extension to adjacent organs, including the recurrent laryngeal nerve, trachea, and esophagus. The diagnosis of CASTLE is based on histology and immunohistochemistry. A 58-year-old female patient complained of hoarseness for one and half years. Right side vocal cord palsy was diagnosed by fiberscopy. Thyroid sonography revealed right thyroid tumors, which were reported to be papillary thyroid carcinoma through FNAC. Total thyroidectomy with central lymph node dissection was performed. Pathologist found 2 isolated malignancy tumors. One patient in the right thyroid lobe had papillary thyroid carcinoma features. The other extrathyroid tumor seemed to be separated from the first tumor and invaded the thyroid capsule. After multiple immunohistochemical studies, PTC synchronous CASTLE was the final diagnosis. Coexisting PTC and CASTLE is very rare. This is the first report to describe a case showing PTC at first, while subsequent pathologic examination revealed the presence of CASTLE in addition to PTC. Since the prognosis of CASTLE is favorable, the treatment is different from other aggressive thyroid cancers, such as poorly differentiated or anaplastic thyroid carcinoma.

Tapia's Syndrome (Concurrent Unilateral Recurrent Laryngeal and Hypoglossal Nerve Palsy) Following Left Retrosigmoid Craniotomy for Schwannoma Resection

Tapia’s syndrome, a unilateral, extracranial combined lesion to the hypoglossal nerve (cranial nerve [CN] XII) and the recurrent laryngeal branch of the vagal nerve (CN X), has been observed to occur after general anesthesia for a variety of surgical procedures. Surgical intraoperative neck positioning and airway management are hypothesized as causative factors. The condition presents with ipsilateral motor paralysis of the tongue and vocal cords. Postoperatively, patients often present with dysphonia, dysphagia, and difficulty swallowing.

We discuss a unique case of Tapia’s syndrome occurring after retrosigmoid craniotomy for left vestibular schwannoma resection in a 42-year-old male. General anesthesia was uneventful with an atraumatic, grade 2a intubation and a normal endotracheal tube cuff pressure of 30 cm of water. The patient was positioned laterally, even though the exact head position was not documented. Institutional practice in these cases is for the head to be maintained neutral or with a slight turn. An uneventful subtotal resection of the tumor was performed after retrosigmoid exposure.

Postoperatively, the patient complained of left-sided mouth tingling, a hoarse voice, and tongue weakness which impacted his ability to chew and swallow. He had mild left-sided facial weakness and decreased sensation in the V1 and V2 distribution of the trigeminal nerve. Postoperative brain MRI showed postsurgical changes without evidence of neurological or vascular involvement.

Fiberoptic endoscopy performed in the otolaryngology clinic showed immobility of the right vocal cord. Consequently, Tapia’s syndrome was diagnosed. He later underwent a right vocal fold injection with Prolaryn gel (Merz North America, Inc, Greensboro, NC, USA) via flexible laryngoscopy with a slight improvement in his dysphonia. At his last visit, he declined further interventions based on acceptable voice quality.

Tapia’s syndrome can occur due to the close anatomical proximity of the hypoglossal and recurrent laryngeal nerves as they pass lateral to the oropharynx and hypopharynx. This predisposes the nerves to anesthetic and surgical insults such as over-stretching of the nerves during head manipulation and trauma to the nerve fibers following laryngoscopy.

Our case report highlights this potential rare complication to anesthetic and surgical teams. Awareness of this concurrent paralysis can assist practitioners to rapidly diagnose and treat patients who present in this way postoperatively. It can also enable avoidance of causative factors and remind practitioners of the importance of meticulous perioperative documentation.

Intermittent Vagal Nerve Stimulation-Associated Vocal Fold Movement Impairment

OBJECTIVES

Implanted vagal nerve stimulators (VNS) are an accepted therapy for refractory seizures. However, VNS have been shown to affect vocal fold function, leading to voice complaints of hoarseness. We present a case of intermittent VNS-related vocal fold paralysis leading to dysphonia and dysphagia with aspiration in a pediatric patient.

METHODS

This is a case report of a patient at a tertiary hospital evaluated in pediatric swallow and voice clinics. Patient and mother gave verbal consent to be included in this case report.

RESULTS

Indirect laryngeal stroboscopy was performed demonstrating full vocal fold mobility with VNS off and left vocal fold paralysis in lateral position and glottic gap with VNS on. Voice measures were performed demonstrating decreased phonation time, lower pitch, and decreased intensity of voice with VNS on. Flexible endoscopic evaluation of swallowing demonstrated deep penetration alone with VNS off and deep penetration with concern for aspiration with VNS on.

CONCLUSIONS

While the majority of cases of vocal fold movement impairment associated with VNS have been noted to have a medialized vocal fold with VNS activation, we describe a case of intermittent vocal fold lateralization associated with VNS activation with resultant voice changes and aspiration.

A case of unilateral recurrent nerve palsy with chronic inflammatory demyelinating polyradiculoneuropathy

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disease in which peripheral sensory and motor nerves of the four limbs are impaired due to autoimmune mechanism-induced demyelinating changes through a 2-month or longer chronic course. The incidence of complication by cranial neuropathy has been reported to be 15%, but there have been very few reports on disorder of the vagus nerve and its branch, the recurrent nerve. We report a patient who developed left recurrent nerve palsy with CIDP. The patient was a 48-year-old male. The disease developed as progressive muscle weakness and numbness of the four limbs 3 years before and was diagnosed as CIDP. The symptoms had been improved by high-dose intravenous gamma-globulin therapy. However, from 2 months before he became aware of breathy hoarseness, and bilateral decreased grip strength and sensory disturbance of the upper and lower limbs recurred and progressed. On laryngoscopy disorder of left vocal fold movement and glottal closure incompetence during phonation were observed, and neurogenic changes were detected in the left thyroarytenoid muscle by needle electromyography for the intrinsic laryngeal muscles. High-dose intravenous gamma-globulin therapy was performed and left vocal fold movement recovered with recovery of bilateral grip strength and sensory disturbance of the upper and lower limbs, and phonation was also normalized.

Voice aspects in sulcus coexisting with benign lesions of the vocal folds

The purpose of this study was to measure the clinical profile of patients with sulcus who had concomitant benign lesions such as polyp, oedema, cyst, nodules, or fibrous mass of the vocal fold. We reviewed the medical charts of 38 patients who had a diagnosis of sulcus type 2 or 3 (according to Ford). The patients were classified into two groups. The study group consisted of 16 subjects who had sulcus and associated benign lesion; 22 patients diagnosed with sulcus alone were enrolled in a control group. We analysed psychosocial (Voice Handicap Index-30), auditory-perceptual (GRBAS), acoustic measures and videostroboscopic images. In the study group, the mean VHI-30 scores of all subscales ranged from moderate to severe handicap. The difference between groups was significant on the emotional (p = 0.004) and physical (p = 0.007) subscales. On GRBAS scale, the majority of patients from both groups exhibited mild hoarseness, breathiness, asthenic or strained voice, although roughness was more frequently rated moderate; the differences between groups were not statistically significant. The most abnormally increased values were achieved for amplitude values of acoustic parameters, but significant difference between groups was found in Soft Phonation Index only (p = 0.049). Concerning glottal closure, the most frequent finding was irregular chink in the study group, and spindle glottic chink in controls; we found significant differences between groups (p = 0.004). In both series of patients, the most frequent abnormal findings were moderately diminished amplitude and moderately restricted mucosal wave, with no significant difference between groups. Patients with sulcus and coexisting benign lesions were more handicapped on the emotional and physical subscales of VHI-30. The most characteristic shape of the glottal gap was irregular chink in the study group, and spindle chink in the control group. Acoustic evaluation of voice showed that the most severe disturbances affected amplitude parameters. The clinical characteristics indicated that the presence of sulcus primarily determines the quality of voice, and that additional benign pathologies do not drastically affect further voice deterioration. The coexistence of secondary benign vocal fold lesions aggravates the difficulties in making a preoperative diagnosis of sulcus. It is important to clinically suspect the possibility of coexistent sulcus to plan the correct treatment and obtain better voice outcomes.

A randomised controlled trial of 7.5-mm and 7.0-mm tracheal tubes vs. 6.5-mm and 6.0-mm tracheal tubes for men and women during laparoscopic surgery

Sore throat after tracheal intubation impairs postoperative recovery. We randomly allocated 172 ASA physical status 1-2 participants, scheduled for laparoscopic lower abdominal surgery, to tracheal intubation with larger tubes (n = 88) or smaller tubes (n = 84), with internal diameters 7.5-mm vs. 6.5-mm for men and 7.0-mm vs. 6.0-mm for women. Primary outcome was the rates of no, mild, moderate or severe sore throat 1 h after surgery, which were 60, 10, 17 and 1 with larger tracheal tubes and 79, 5, 0 and 0 with smaller tubes, p < 0.001. The equivalent rates 24 h after surgery were 64, 16, 8 and 0 vs. 74, 6, 3 and 1, p = 0.037. Intra-operative ventilatory variables were unaffected by tube diameter, including peak inspiratory pressure, plateau pressure and end-tidal carbon dioxide partial pressure. In summary, smaller tracheal tubes benefitted patients having laparoscopic operations.

Validation and Classification of the 9-Item Voice Handicap Index (VHI-9i)

The international nine-item Voice Handicap Index (VHI-9i) is a clinically established short-scale version of the original VHI, quantifying the patients’ self-assessed vocal handicap. However, the current vocal impairment classification is based on percentiles. The main goals of this study were to establish test–retest reliability and a sound statistical basis for VHI-9i severity levels. Between 2009 and 2021, 17,660 consecutive cases were documented. A total of 416 test–retest pairs and 3661 unique cases with complete multidimensional voice diagnostics were statistically analyzed. Classification candidates were the overall self-assessed vocal impairment (VHIs) on a four-point Likert scale, the dysphonia severity index (DSI), the vocal extent measure (VEM), and the auditory–perceptual evaluation (GRB scale). The test–retest correlation of VHI-9i total scores was very high (r = 0.919, p < 0.01). Reliability was excellent regardless of gender or professional voice use, with negligible dependency on age. The VHIs correlated best with the VHI-9i, whereas statistical calculations proved that DSI, VEM, and GRB are unsuitable classification criteria. Based on ROC analysis, we suggest modifying the former VHI-9i severity categories as follows: 0 (healthy): 0 ≤ 7; 1 (mild): 8 ≤ 16; 2 (moderate): 17 ≤ 26; and 3 (severe): 27 ≤ 36.

Transcutaneous ultrasound: An adjunct way to evaluate the intra-false vocal cord pathology-learning from a case of laryngeal Rosai-Dorfman disease

In clinical practice, it is sometimes difficult to evaluate the intra-false vocal fold lesion. Transcutaneous ultrasound can be an option to evaluate the soft tissue lesion within the right false vocal cord in a 65-year-old man with laryngeal Rosai-Dorfman disease presenting with hoarseness and right false cord swelling.

Schwannoma of the Supraglottis

Hoarseness lasting greater than 2 weeks should be thoroughly evaluated. Here, a case is presented of a 38-year-old female with a 10-year history of dysphonia. Endoscopic examination confirmed the presence of a supraglottic mass, for which operative biopsy and imaging were performed. Pathology confirmed the diagnosis of supraglottic schwannoma. This was excised endoscopically with close management postoperatively to monitor for rapid recurrence and airway compromise. At one month postoperatively, the patient is still mildly dysphonic but vocally improved and the operative site continues to heal well.