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The Importance of Inspiratory Maneuver for Benign Laryngeal Lesions

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The Importance of Inspiratory Maneuver for Benign Laryngeal Lesions THIEME Original Research 513 The Importance of Inspiratory Maneuver for Benign Laryngeal Lesions Marília Batista Costa1 Taynara Oliveira Ledo1 Mariana Delgado Fernandes1 Romualdo Suzano Louzeiro Tiago1 1 Otorhinolaryngology Department, Hospital do Servidor Publico Address for correspondence Marília Batista Costa, MD, Estadual de Sao Paulo, Sao Paulo, SP, Brazil Otorrinolaringologia, Hospital do Servidor Publico Estadual de São Paulo, Rua Pedro de Toledo, 1800, Vila Clementino, São Paulo, SP, Int Arch Otorhinolaryngol 2020;24(4):e513–e517. 04029-000, Brazil (e-mail: [email protected]). Abstract Introduction Inspiratory maneuver corresponds to a simple method used during videolaryngoscopy to increase characterizations of laryngeal findings, through the movement of the vocal fold cover and exposure of the ligament, facilitating its evaluation. Objective To evaluate the increase in diagnosis of benign laryngeal lesions from the usage of inspiratory maneuvers during videolaryngoscopy in patients with or without vocal complaints. Methods A cross-sectional study performed from March 1 to July 1, 2018, in the Laryngology sector of a tertiary hospital. The age of the patients varied from 18 to 60 years old. They were divided into two groups, symptomatic and asymptomatic vocals, and evaluated through videolaryngoscopy together with inspiratory maneu- vers. The exams were recorded and later evaluated by three trained laryngologists who determined the laryngeal lesions before and after the inspiratory maneuver. Results Therewere60patientsinthissample,41ofwhichwerevocalsymptomatic and 19 asymptomatic. The majority was female and the main complaint was about dysphonia. Before the inspiratory maneuver, the most observed lesions in both groups were chronic laryngitis, followed by vascular dysgenesis. After the inspiratory maneu- Keywords ver, sulcus vocalis was the most frequent additional finding. ► diagnosis Conclusion With the inspiratory maneuver, it was possible to increase the identifica- ► vocal cords tion of structural lesions in the vocal fold, and the most frequent lesion in patients with ► laryngoscopy or without vocal complaints was sulcus vocalis. Introduction A precise diagnosis is essential for therapeutic decisions as well as for the instructions to the patients about their One of the functions of the larynx is phonation. Voice is illness and possible after effects.3,4 The diagnosis is made produced through the repeated movement of the vocal fold usually through endoscopic visualization, either by video- cover, producing a mucosal wave. The flexibility of the vocal laryngoscopy with a rigid telescope or rhino-laryngo flexible fold is essential to promote the appropriate glottic vibra- fiberscope or videolaryngostroboscopy.5 It is also possible to tion.1 However, the formation of a mucosal wave is modified do a suspension microlaryngoscopy, considered the best to by benign laryngeal lesions, its main examples being nod- diagnose benign laryngeal lesions.6 ules, polyps, Reinke edema and minor structural alterations The inspiratory maneuver was initially described in 1957 (MSAs).2 by Powers et al7 from a radiological analysis of the larynx or received DOI https://doi.org/ Copyright © 2020 by Thieme Revinter December 17, 2018 10.1055/s-0040-1702968. Publicações Ltda, Rio de Janeiro, Brazil accepted ISSN 1809-9777. July 18, 2019 514 The Importance of Inspiratory Maneuver for Benign Laryngeal Lesions Costa et al. laryngography. Only in 2003 Kothe et al8 indicated its use to The present work was performed in two steps: stimulate a precise way to classify Reinke edema. This 1. Data collection and videolaryngoscopy: a structured maneuver corresponds to a simple method used during interview in which epidemiological data was gathered, such videolaryngoscopy. For this, which can be done through a as age, gender, clinical complaints (dysphonia, cough, throat rigid telescope or rhino-laryngo flexible fiberscope, the clearing, globus pharyngeus, dysphagia, pyrosis, pain, patient has to, after exhalation, inhale deeply and noisily. patients without voice complaints, but having to do admis- Thus, there is a better definition of the viscoelastic properties sion exams to work as teachers). of the vocal folds and its cover alterations giving the suction The instruments used for videolaryngoscopy were: Ferrari of the free edge of the vocal fold toward the subglottis, with a light source (E 50S, Ferrari Medical, São Paulo, SP, Brazil); – good delimitation of the vocal ligament.8 10 Olympus OTV-SC camera system (Olympus, Tokyo, Japan); The objective of the present study is to evaluate the Precision larynx rigid telescope (Precision 8mmx70°, Richards increase in the diagnosis of benign laryngeal lesions using Medical, São Paulo, SP, Brazil), 70° angulation; MZ Medical inspiratory maneuver during videolaryngoscopy in patients external microphone system (MZ Medical Products, São Paulo, with or without vocal complaints. SP, Brazil); Sony TV monitor model PVM-2053MD (Sony Cor- poration, Tokyo, Japan). All videos werebacked up in a database, Methods using a MyGica video recorder (MyGica, Shenzhen, China). Patients were asked to sit, with their tonguess out, wrapped Patients in the present cross-sectional study underwent a in gauze and kept in this position by the assessor’s fingers videolaryngoscopy at the ambulatory in the Laryngology pressure. The rigid telescope was inserted toward the orophar- sector of a tertiary hospital. They were analyzed from ynx, visualizing the larynx. Patients with gag reflex received March 1 to July 1, 2018. The study has been evaluated and topical anesthesia in the oropharynx with 10% lidocaine spray. approved by the hospital’s Ethical Committee in Research, Initially, a full larynx anatomy evaluation was made, under the CAAE number 85767318.4.0000.5463. including documentation of the supraglottis (breathing The research included patients between 18 and 60 years area), subglottis and trachea region. Afterwards, there old who had adequately done videolaryngoscopy using in- was a functional evaluation through sustained phonation spiratory maneuver and filled out the written informed of the /i/ vowel, resulting in the elevation of the larynx and consent form. anteriorization of the epiglottis, facilitating visualization of The exclusion criteria established were: suspicion or the laryngeal structures. In the end, the patients were asked confirmation of malign laryngeal lesion; previous laryngeal to do the inspiratory maneuver, which is a long and noisy procedures, such as laryngeal microsurgery, cordectomy, inhale after exhaling. partial or total laryngectomy; radiotherapy/chemotherapy To compare, patients were divided into two groups in cervical regions; replacement of rigid telescope by rhino- according to their clinical vocal complaints: symptomatic laryngo flexible fiberscope resulting from intense nauseous or asymptomatic. In the first group, the symptoms were: reflex; difficulty or unsatisfactory inspiratory maneuver; hoarseness and vocal fatigue. Other complaints mentioned in laryngeal candidiasis compromising the vocal folds. both groups were: pyrosis, throat clearing, pain, dysphagia, Patients > 60 years old were excluded due to the natural globus pharyngeus and cough. physiological aging and atrophy of the intrinsic laryngeal 2. Video analyses: the videos were backed up in a database muscles of the age, therefore the vocal folds gain a curved and afterwards watched by three experienced laryngologists aspect with a higher prominence in the vocal process. separately. Videos were shown at normal speed, slow motion Related to it there is a reduction of mucous and saliva, or paused, according to the necessity of the evaluator. These restricting the vibrating capacity of the vocal folds. professionals determined the findings and a possible diag- There was a total of 201 patients, 141 of them were nosis in each video before and after the maneuver, to confirm excluded. All reasons for exclusion are in ►Table 1. if the inspiratory maneuver would contribute to the addi- tional alterations or if it would alter the initial diagnosis. The evaluators were not aware of the identification of the Table 1 Causes and frequencies of patient exclusion patients or of their vocal symptoms. The additional laryngeal alterations were: signs of chronic Exclusion Reason n (%) laryngitis (hyperemia and edema of vocal folds, interarytenoid Age > 60 years old 89 (44.3%) edema and subglottic edema), vocal nodules, pseudocyst, Previous surgery 26 (12.9%) polyps, epidermoid cyst, sulcus vocalis, laryngeal asymmetry, Intense nauseous reflex 17 (8.5%) Reinke edema, leukoplakia, mucosal thickening, vascular dysgenesis, vocal cord paresis, contact ulcer, laryngocele, Age < 18 years old 3 (1.5%) laryngeal candidiasis, as well as exams without abnormalities. Unsatisfactory inspiratory maneuver 3 (1.5%) The same patient can have more than one diagnosed lesion. Previous radiotherapy or chemotherapy 2 (1%) For the statistic analysis, the lesions were counted in each Laryngeal candidiasis (vocal folds) 1 (0.5%) vocal fold. Typically bilateral lesions, such as vocal nodule and Reinke edema, and the suggestive findings of laryngitis Total 141 (70.2%) posterior (hyperemia and edema of interarytenoid region) International Archives of Otorhinolaryngology Vol. 24 No. 4/2020 The Importance of Inspiratory Maneuver for Benign Laryngeal Lesions Costa et al. 515 were evaluated as unique bodies. Lesions classified as “con- the need for admission exams to teach were 26.7% of the
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