Acid-Induced Laryngospasm in a Canine Model

A canine model was used to investigate the efferent laryngeal responses to stimulation by topically applied acid and pepsin. Five adult mongrel dogs were studied. Electromyographic recordings from the thyroarytenoid muscle were measured with hooked-wire electrodes as an acid solution (normal saline/hydrochloric acid at pH 6.0, 5.0, 4.0, 3.0, 2.5, 2.0, 1.5, and 1.0) was sequentially instilled into the larynx. Laryngospasm (tonic, sustained contraction of the thyroarytenoid muscle) occurred in all animals at pH 2.5 to 2.0 or less. Control substances such as neutral pH isotonic saline, hypotonic saline, hypertonic saline, water, and pepsin alone failed to produce laryngospasm. Next, solutions containing both acid (in the same pH range) and pepsin were tested. The laryngeal responses were similar to those of acid alone. The superior laryngeal nerves were sectioned bilaterally and the above experiments repeated. None of the test solutions produced laryngospasm; however, when capsaicin (1%) was instilled into the subglottis, laryngospasm occurred. Thus, chemoreceptors in the subglottis (supplied by the recurrent laryngeal nerves) appear to be responsive to capsaicin stimulation but not to acid stimulation. The data suggest that pH-sensitive chemoreceptors in the canine larynx cause laryngospasm (when the pH of the test solution is 2.5 or less) and that these acid receptors are supplied by the superior laryngeal nerves.     

Are bulb syringe irrigators a potential source of bacterial contamination in chronic rhinosinusitis?

BACKGROUND: The purpose of this study was to determine if bulb syringe irrigators are a potential source for bacterial contamination in patients with chronic rhinosinusitis. METHODS: Standard 3-oz bulb syringe irrigators (n = 24) were each flushed with the following solutions twice daily: A (n = 8), sterile isotonic saline; B (n = 8), prepared hypertonic saline (3 tsp table salt/L of sterile water); and C (n = 8), prepared baking soda/saline (1 tsp table salt + 1 tsp baking soda/L of commercial sterile water). Syringes were stored on a residential bathroom counter, and two from each group were harvested for culture weekly for 4 weeks. RESULTS: There was no growth from syringes irrigated with any of the three solutions after the first 7 days of irrigation. After the entire 4-week study period, potential pathogens were recovered from 6/8 (75%) bulbs from group A, 0/8 bulbs from group B, and 1/8 bulbs (12.5%) from group C. All positive cultures revealed growth by 1-2 days postinoculation (p = 0.002). The organism recovered from syringes in group A was Pseudomonas fluorescens in all six specimens. The one positive culture in group C represented a single colony of Gram-positive cocci. CONCLUSION: Under realistic conditions, bulb syringes are susceptible to contamination with potential bacterial pathogens, particularly when using unbuffered isotonic saline.     

Mechanism and rate of middle ear fluid absorption

Several mechanisms have been suggested to explain the clearance of fluids from the middle ear. These include a pumping action through the eustachian tube, mucociliary beating through the tube, outflow of water to the blood due to osmotic gradients and an active Na(+) transport driving water absorption. In order to assess these mechanisms, the middle ear cavity of paralyzed, ventilated (eustachian tube occluded) guinea pigs was filled with fluids varying in osmotic pressure (hypotonic, isotonic, hypertonic) to which a vertical tube was attached. The change in height of fluid in the tube was taken as a measure of changes in middle ear fluid volume. A greater fluid volume reduction was seen with the hypotonic (1/5 saline) solution. A small volume increase was observed with the hypertonic solution. These results provide evidence that in these experimental conditions, water absorption due to osmotic gradients can contribute to middle ear fluid clearance.     

Physiologic and hypertonic saline solutions impair ciliary activity in vitro

OBJECTIVE/HYPOTHESIS: Physiologic saline (NaCl 0.9%) is commonly used in treating acute and chronic rhinosinusitis. Moreover, physiologic saline is used as a control medium, vehicle, or solvent in studies on ciliary beat frequency (CBF). Hypertonic saline (NaCl 7% and 14.4%) has been applied in attempts to enhance mucociliary transport in patients with cystic fibrosis or asthma and in healthy subjects. Therefore the objective of this study is to document in vitro effects of saline solutions in different concentrations on CBF. STUDY DESIGN: Experimental, in vitro. METHODS: The effects on CBF of cryopreserved mucosa of the sphenoidal sinus was measured by a photoelectrical method. Initial frequencies, measured in Locke-Ringer's solution (LR), were compared with CBF after exposure to NaCl in concentrations of 0.9%, 7.0%, and 14.4% (w/v). RESULTS: NaCl 0.9% has a moderately negative effect on CBF. The 7% solution leads to a complete ciliostasis within 5 minutes, although this effect turns out to be reversible after rinsing with LR. A hypertonic solution of 14.4% has an irreversible ciliostatic effect. CONCLUSION: LR is an isotonic solution that has no effect on CBF. Therefore it is probable that this solution is more appropriate than saline for nasal irrigation and nebulization or antral lavage. Moreover, the results of this study suggest that mucolytic effects induced by hyperosmolarity should be attained preferably with hypertonic saline 7% in patients with cystic fibrosis or asthma. At this concentration, the ciliostatic effect is reversible, whereas irreversible changes are to be expected at higher concentrations.     

Effects of buffered 2.3%, buffered 0.9%, and non-buffered 0.9% irrigation solutions on nasal mucosa after septoplasty

A prospective randomized study was designed to compare the effect of different irrigation solutions on mucociliary clearance and nasal patency and to compare the limitations of the used solutions, such as nasal burning by a visual analog scale. Forty-five patients who underwent septoplasty were divided into three groups postoperatively. Each group was administered with 2.3% buffered hypertonic seawater, buffered isotonic saline solution and non-buffered isotonic saline, respectively, as irrigation fluid. Saccharine test and acoustic rhinometer were used to determine mucociliary activity and nasal patency. Patients were asked about the burning sensation using a 10-cm visual analog scale. There was no significant difference in saccharine clearance time (SCT) on the 5th postoperative day between the three groups (P = 0.07). On the 20th day, there was a significant difference in SCT between the hypertonic buffered seawater group and non-buffered isotonic saline (P = 0.003). Buffered hypertonic seawater improved nasal airway patency more than the buffered isotonic saline (P = 0.004). Buffered hypertonic solutions used after endonasal surgery have been advantageous for both mucociliary clearance and postoperative decongestion.     

高渗盐水对慢性鼻窦炎患者鼻腔黏膜纤毛清除功能的影响

目的：探讨高渗盐水对成年慢性鼻窦炎患者鼻腔黏膜纤毛运动功能的影响。方法：选取住院待行鼻内窥镜下慢性鼻窦炎手术的患者为研究对象,用鼻腔黏膜纤毛清除功能糖精清除率法检测正常状态、鼻腔生理盐水喷雾和高渗盐水喷雾后糖精清除时间,统计学方法采用Wilcoxon检验。结果：慢性鼻窦炎患者平均糖精清除时间为19.62min,生理盐水和高渗盐水冲洗后患者平均糖精清除时间分别为17.74min和13.22min。与冲洗前相比,生理盐水未明显加快糖精清除速度（P＞0.05）,而高渗盐水冲洗后患者平均糖精清除时间明显缩短（P＜0.01）,平均缩短6.4min。结论：高渗盐水可使慢性鼻窦炎患者的黏膜清除时间缩短,促进黏膜的清除功能。等渗生理盐水对黏膜清除时间影响不明显。     

Effects of different temperatures of saline and isotonic saline solution on changes in functional characteristics of the nasal cavity

The influence of different temperatures (22 degrees capital ES, Cyrillic, 30 degrees capital ES, Cyrillic, 37 degrees capital ES, Cyrillic) of 2% saline solution and isotonic saline solution on the breathing function of the nasal cavity and transport function of the nasal mucosa in nasal shower with these solutions was studied in healthy volunteers. Nasal shower technique with application of the device Rhinolife is described. It was found that nasal shower with isotonic saline solution at temperature of 37 degrees C is optimal as it does not depress a nasal breathing function and is comfortable for the patient.     

Oral breathing challenge in participants with vocal attrition.

Vocal folds undergo osmotic challenge by mouth breathing during singing, exercising, and loud speaking. Just 15 min of obligatory oral breathing, to dry the vocal folds, increases phonation threshold pressure (Pth) and expiratory vocal effort in healthy speakers (M. Sivasankar & K. Fisher, 2002). We questioned whether oral breathing is more detrimental to phonation in healthy participants with a history of temporary vocal attrition. The effects of a 15-min oral or nasal breathing challenge on Pth and perceived expiratory vocal effort were compared for participants reporting symptoms of vocal attrition (N = 18, ages 19-38 years) and normal controls (N = 20, ages 19-33 years). Post-challenge-prechallenge differences in Pth (deltaPth) and effort (deltaEffort) revealed that oral breathing, but not nasal breathing, increased Pth (p < .001 ) and effort (p < .001) at low, comfortable, and high pitch. deltaPth was significantly greater in participants with vocal attrition than in normal controls (p < .001). Nasal breathing reduced Pth for all controls but not for all participants reporting vocal attrition. deltaPth was significantly and linearly correlated with deltaEffort (rvocal attrition = .81, p < .001; rcontrol = .84, p < .001). We speculate that the greater increases in Pth in participants reporting vocal attrition may result from delayed or inadequate compensatory response to superficial laryngeal dehydration. Obligatory oral breathing may place voice users at risk for exacerbating vocal attrition. That sol layer depletion by obligatory oral breathing increased Pth and vocal effort provides support for the role of superficial hydration in maintaining ease of phonation.     

Do vocal warm-up exercises alleviate vocal fatigue?

Vocal warm-up (WU) exercises of varying types and durations have been suggested as a way of improving vocal function. However, limited research has been conducted to assess the effects of vocal WU exercises on normal or disordered voices. This study attempted to manipulate vocal function, assessed by phonation threshold pressure (PTP) and self-perceived phonatory effort (PPE) at 3 pitches, in 8 young women who reported symptoms of chronic vocal fatigue. Predictions were that PTP and PPE would decrease after 20 min of vocal WU exercises, increase after 1 hr of loud reading, and decrease after 30 min of vocal silence. Furthermore, greater increases in PTP and PPE were expected when the loud-reading task was preceded by a placebo condition of vocal rest than by vocal WU exercises. Results failed to reveal statistically significant changes in PTP or PPE after any of the experimental tasks. High between-subject variability contributed to this result. Removal of 1 outlier from the sample resulted in a statistically significant difference for PTP across tasks, although post hoc pairwise comparisons failed to detect specific effects. Informal inspection of the data indicated that the most obvious difference was an increase in PTP after the loud-reading task at the highest pitch.     

Efficacy of nasal irrigation with hypertonic saline on chronic rhinosinusitis: systematic review and meta-analysis

IntroductionCurrently, several different concentrations of saline are recommended for use in nasal irrigation. Increasing studies show that nasal irrigation with hypertonic saline is more effective than traditional saline in the treatment of rhinosinusitis, but there have been few systematic analyses of the effect of nasal irrigation with hypertonic saline on chronic rhinosinusitis.ObjectiveWe sought to compare the effects of hypertonic saline and isotonic saline in the treatment of rhinosinusitis in order to provide a reference for clinical nasal irrigation for chronic rhinosinusitis treatment.MethodsMedline, cochrane library, EMBASE, PubMed, Chinese biomedical journal database, China national knowledge infrastructure, Wanfang database, and other databases were searched, and the searching was supplemented by manual searches for relevant references to treatment of rhinosinusitis by saline nasal irrigation. The last retrieval date was March 2018. The included studies were evaluated for quality, and data were extracted for meta-analysis using RevMan 5.3.ResultsSeven studies were included. Effects favoring hypertonic saline on nasal symptoms were greater in 4 subgroups. These were (1) patients with nasal secretion (SMD = 1.52; 95% CI: 1.04, 2.00; p < 0.01), (2) patients with congestion (SMD = 1.52; 95% CI: 1.04, 2.00; p < 0.01), (3) patients with headache (SMD = 0.82; 95% CI: 0.38, 1.26; p < 0.01), (4) patients with overall symptomatic relief (SMD = 1.63; 95% CI: 0.83, 2.44; p < 0.01). However, no difference was shown in smell improvement (SMD = 0.47; 95% CI: −0.65, 1.59; p = 0.41) and radiologic scores improvement (SMD = 2.44; 95% CI: -3.14, 8.02; p < 0.01). Besides, hypertonic saline showed greater improvement in mucociliary clearance time scores than did the isotonic saline group (SMD = 1.19; 95% CI: 0.78, 1.60; p < 0.01). Hypertonic saline brought greater minor adverse effects.ConclusionCompared with isotonic saline, hypertonic saline nasal irrigation for the treatment of chronic rhinosinusitis is significantly more effective and has mild side effects in improving nasal symptoms and ciliary movement, but there is no significant difference in imaging findings and smell improvement. Although hypertonic saline is worthy of widespread use in clinical practice, it is still necessary to further study the exact manner and concentration of nasal irrigation.     

Lidocaine block of the recurrent laryngeal nerve in adductor spasmodic dysphonia: a multidimensional assessment

OBJECTIVES/HYPOTHESIS: Lidocaine block of the recurrent laryngeal nerve (RLN) has been reported as a procedure for surgical selection of patients with adductor spasmodic dysphonia (ADSD). However, its effects on phonation have not been rigorously assessed in a prospective fashion using strict entry criteria and multiple measures of phonatory function. This investigation assessed the phonatory effects of RLN lidocaine block in ADSD to explore its potential as a diagnostic tool. STUDY DESIGN: Single group, pre/postexperimental trial. METHODS: Twenty-one consecutive patients with suspected ADSD underwent unilateral RLN block, causing temporary ipsilateral vocal fold paralysis. Voices were recorded before and during the block. Patients completed self-ratings of overall level of dysphonia severity, vocal effort, and laryngeal tightness. Blinded listeners completed auditory-perceptual ratings, and the frequency of phonatory breaks was acoustically analyzed. RESULTS: During the block, patients reported significant reductions on overall severity (P = .045), vocal effort (P < .001), and laryngeal tightness (P = .002). Listeners rated the voices during the block as significantly more breathy (P < .001), less strained (P < .001), and less severe (P = .059). Acoustic analysis confirmed significantly fewer phonatory breaks during the block (P < .001). Patient-based ratings of improvement were more consistent than listener ratings, and reduction in overall severity correlated with perceived breathiness. CONCLUSIONS: Although individuals varied in their outcomes, group results suggest that response to RLN lidocaine block warrants further study as a possible diagnostic tool in ADSD.     

l-Epinephrine and dexamethasone in postextubation airway obstruction: A prospective, randomized, double-blind placebo-controlled study

Purpose

This prospective randomized double-blind placebo-controlled study paired trial groups to investigate the effect of intravenous dexamethasone and nebulized l-epinephrine on the clinical development of postextubation laryngeal edema.

Material and methods

Sixty-four patients aged 1 day to 12 years who needed intubation from August/1997 to February/1999 in the Pediatric Intensive Care Unit (PICU) of Santa Casa de São Paulo School of Medicine were paired according to age, height and weight, anthropometric z-scores, duration of tracheal intubation and number of intubation attempts. Patients received intravenous dexamethasone (0.2 mg/kg every 6 h), with or without nebulized l-epinephrine (0.5 mg/kg every 4 h) in the study groups; in the control groups, they received nebulized or intravenous isotonic saline solution, or both. Dependent variables: frequency and severity of the laryngeal edema (according to Westley Clinical Scoring System), as well as the time interval (min) between extubation and the first postextubation laryngeal edema scores. Postextubation respiratory rate and transcutaneous oxygen saturation were employed as indicators of the clinical conditions for extubation.

Results

Laryngeal edema frequencies did not change according to treatments, χ² (3, N = 64) = 0.58, p > 0.05, and the highest scores were not reached in the 24 h after extubation, (3, N = 16) = 1.03, p > 0.05.

Conclusions

Dexamethasone and l-epinephrine did not reduce the clinical progression of airway obstruction due to laryngeal edema in the early postextubation period.     

A novel view of prophylaxis and treatment of chronic adenoiditis in children

The present clinical study had the objective to evaluate the role of a hypertonic solution of sterile water from the Adriatic Sea in the prevention and treatment of chronic adenoiditis in children. It included 30 children aged from 2.5 to 15 years. The control group was comprised of 30 children treated by intransal drop infusion of physiological saline followed by irrigation of the nasal cavity with framicetin as recommended by the manufacturer. The study failed to reveal a significant difference (P > 0.05) between dynamics of the symptoms of chronic adenoiditis in the patients of either group assessed based on the 10-point analog visual scale. However, the frequency of relapses of adenoiditis during the observation period (3 months) was significantly lower in the patients treated with the hypertonic solution of sterile seawater. Microbiological investigations of the material from the pharyngonasal cavity showed no difference between the occurrence of tansient bacterial microflora in the patients of the study and control groups.     

Effect of acid and pepsin on glottic wound healing: a simulated reflux model

OBJECTIVE: To evaluate the effects of acid and pepsin on the healing of traumatized vocal folds in a simulated reflux model. Gastroesophageal reflux is related to various laryngeal manifestations. However, there is a lack of established reflux animal models that would ensure longer observation periods. DESIGN: A prospective randomized animal study. INTERVENTIONS: Forty-two rabbits underwent a stripping procedure of the unilateral glottis and catheter insertion under transoral endoscopic guidance. The animals were randomly assigned to a control group (n = 21; isotonic sodium chloride was used) or a reflux group (n = 21, acid and pepsin were used). They received intrapharyngeal catheter irrigation with 3 mL of isotonic sodium chloride or a solution of acid with a pH of 3 and pepsin, 0.3 mg/mL, twice daily for 4 or 8 weeks after surgery. MAIN OUTCOME MEASURES: Gross and histologic findings of the preinjured glottides of the 2 groups were compared. RESULTS: The catheter extrusion rate was significantly low (6%), and any catheter problems were immediately solved by reinsertion or reconnection. The extent of glottic scarring and frequency of granulation formation were higher in the reflux group compared with the control group (P<.05). Histologic inflammation scores and collagen deposition were significantly greater in the reflux group compared with the control group (P<.05). CONCLUSIONS: Our data suggest that glottic wound healing is significantly affected by acid and pepsin. Antireflux treatment can be advocated to minimize further injury caused by gastroesophageal reflux in patients who undergo laryngeal surgery.     

Measurement of water loss in human nasal mucosa

BACKGROUND: Regulation of the barrier function in the nasal epithelium seems to be affected by the pathogenesis of allergic rhinitis. The measurement of transepidermal water loss has proven to be an important noninvasive method for assessing the efficiency of the skin as a protective barrier. Although the nasal mucosal epithelium also has such a protective function, the precise mechanism still is unknown. METHODS: We studied the alteration of nasal mucosal water loss in the basal state and after the nontraumatic applications of physiological saline, hypertonic saline (10% NaCl), nasal barrier cream, and 10% glycerol on the mucosal surface of the inferior turbinate. RESULTS: We observed that nasal mucosal water loss was increased by hypertonic saline and decreased by nasal cream and glycerol. CONCLUSION: For the first time, we showed the human nasal mucosal water loss both in the basal state and after topical application of various substances.     

Quincke's edema: diagnosis and management of 102 patients with sudden upper airway obstruction

BACKGROUND: Hereditary angioedema (HAE) is extremely rare and clinically characterized by recurrent and self-limiting skin, intestinal and life threatening laryngeal edema. Because of the danger of asphyxiation, it is vital that acute attacks of laryngeal edema be interrupted immediately. The aim of this study is to provide information on the incidence, diagnosis and treatment of laryngeal edema with upper airway obstruction in general and due to HAE. METHODS: 102 patients with swelling of the larynx and difficulty in breathing (stridor) and 21 patients with a manifest HAE were surveyed at the Department of Otorhinolaryngology, Head and Neck Surgery of the Ludwig-Maximilians-University of Munich from 2001 to 2004. RESULTS: 63% of the laryngeal swellings with airway obstruction were due to radiotherapy in cancer and the intake of ACE-Inhibitors. Just 22% were due to allergic reactions. Only one patient (< 1%) suffered from HAE. All patients were treated with intravenous steroids and anti-histamines successfully, except the HAE patient. After emergency coniotomy the patient was treated with purified C1 inhibitor concentrate (C1-INH). CONCLUSIONS: According to our experience almost all patients with laryngeal swelling and upper airway obstruction react well to the standard therapy with steroids and anti-histamines. In contrast these drugs have no effect on HAE. Replacement therapy with C1-INH has proved to be effective. The challenge is to realize whether an airway obstruction is due to HAE or not. In this case, careful observation, the right medication and an appropriate airway management are lifesaving. The possibility of sudden airway obstruction and asphyxiation must be discussed with these patients and their relatives.     

Laryngectomees' and nonlaryngectomees' perceptions of three methods of alaryngeal voicing

The purpose of this investigation was to compare the proficiency ratings made by laryngectomee and nonlaryngectomee judges when evaluating videotaped samples of laryngeal and alaryngeal speakers. A group of laryngectomee judges and three groups of nonlaryngectomized judges completed proficiency ratings for the following speakers: laryngeal (n = 10); electrolarynx (n = 11); esophageal (n = 12); and tracheoesophageal puncture (n = 10). Significant differences between laryngectomee and nonlaryngectomee judges were found when rating alaryngeal speakers, but not when rating normal, laryngeal speakers. Differences in judge group ratings varied according to the voicing method of the speakers and according to the vocal parameter being rated.