The Importance of Inspiratory Maneuver for Benign Laryngeal Lesions

THIEME Original Research The Importance of Inspiratory Maneuver for Benign Laryngeal Lesions Marília Batista Costa1 Taynara Oliveira Ledo1 Romualdo Suzano Louzeiro Tiago1 1 Otorhinolaryngology Department, Hospital do Servidor Publico Estadual de Sao Paulo, Sao Paulo, SP, Brazil Int Arch Otorhinolaryngol 2020;24(4):e513–e517. Abstract Keywords ► diagnosis ► vocal cords ► laryngoscopy Address for correspondence Marília Batista Costa, MD, Otorrinolaringologia, Hospital do Servidor Publico Estadual de São Paulo, Rua Pedro de Toledo, 1800, Vila Clementino, São Paulo, SP, 04029-000, Brazil (e-mail: ). 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 maneuvers. The exams were recorded and later evaluated by three trained laryngologists who determined the laryngeal lesions before and after the inspiratory maneuver. Results There were 60 patients in this sample, 41 of which were vocal symptomatic 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 maneuver, sulcus vocalis was the most frequent additional finding. Conclusion With the inspiratory maneuver, it was possible to increase the identification of structural lesions in the vocal fold, and the most frequent lesion in patients with or without vocal complaints was sulcus vocalis. Introduction One of the functions of the larynx is phonation. Voice is produced through the repeated movement of the vocal fold cover, producing a mucosal wave. The flexibility of the vocal fold is essential to promote the appropriate glottic vibration.1 However, the formation of a mucosal wave is modified by benign laryngeal lesions, its main examples being nodules, polyps, Reinke edema and minor structural alterations (MSAs).2 received December 17, 2018 accepted July 18, 2019 Mariana Delgado Fernandes1 DOI https://doi.org/ 10.1055/s-0040-1702968. ISSN 1809-9777. A precise diagnosis is essential for therapeutic decisions as well as for the instructions to the patients about their illness and possible after effects.3,4 The diagnosis is made usually through endoscopic visualization, either by videolaryngoscopy with a rigid telescope or rhino-laryngo flexible fiberscope or videolaryngostroboscopy.5 It is also possible to do a suspension microlaryngoscopy, considered the best to diagnose benign laryngeal lesions.6 The inspiratory maneuver was initially described in 1957 by Powers et al7 from a radiological analysis of the larynx or Copyright © 2020 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil 513 514 The Importance of Inspiratory Maneuver for Benign Laryngeal Lesions laryngography. Only in 2003 Kothe et al8 indicated its use to stimulate a precise way to classify Reinke edema. This maneuver corresponds to a simple method used during videolaryngoscopy. For this, which can be done through a rigid telescope or rhino-laryngo flexible fiberscope, the patient has to, after exhalation, inhale deeply and noisily. Thus, there is a better definition of the viscoelastic properties of the vocal folds and its cover alterations giving the suction of the free edge of the vocal fold toward the subglottis, with a good delimitation of the vocal ligament.8–10 The objective of the present study is to evaluate the increase in the diagnosis of benign laryngeal lesions using inspiratory maneuver during videolaryngoscopy in patients with or without vocal complaints. Methods Patients in the present cross-sectional study underwent a videolaryngoscopy at the ambulatory in the Laryngology sector of a tertiary hospital. They were analyzed from March 1 to July 1, 2018. The study has been evaluated and approved by the hospital’s Ethical Committee in Research, under the CAAE number 85767318.4.0000.5463. The research included patients between 18 and 60 years old who had adequately done videolaryngoscopy using inspiratory maneuver and filled out the written informed consent form. The exclusion criteria established were: suspicion or confirmation of malign laryngeal lesion; previous laryngeal procedures, such as laryngeal microsurgery, cordectomy, partial or total laryngectomy; radiotherapy/chemotherapy in cervical regions; replacement of rigid telescope by rhinolaryngo flexible fiberscope resulting from intense nauseous reflex; difficulty or unsatisfactory inspiratory maneuver; laryngeal candidiasis compromising the vocal folds. Patients > 60 years old were excluded due to the natural physiological aging and atrophy of the intrinsic laryngeal muscles of the age, therefore the vocal folds gain a curved aspect with a higher prominence in the vocal process. Related to it there is a reduction of mucous and saliva, restricting the vibrating capacity of the vocal folds. There was a total of 201 patients, 141 of them were excluded. All reasons for exclusion are in ►Table 1. Table 1 Causes and frequencies of patient exclusion Exclusion Reason n (%) Age > 60 years old 89 (44.3%) Previous surgery 26 (12.9%) Intense nauseous reflex 17 (8.5%) Age < 18 years old 3 (1.5%) Unsatisfactory inspiratory maneuver 3 (1.5%) Previous radiotherapy or chemotherapy 2 (1%) Laryngeal candidiasis (vocal folds) 1 (0.5%) Total 141 (70.2%) International Archives of Otorhinolaryngology Vol. 24 No. 4/2020 Costa et al. The present work was performed in two steps: 1. Data collection and videolaryngoscopy: a structured interview in which epidemiological data was gathered, such as age, gender, clinical complaints (dysphonia, cough, throat clearing, globus pharyngeus, dysphagia, pyrosis, pain, patients without voice complaints, but having to do admission exams to work as teachers). The instruments used for videolaryngoscopy were: Ferrari light source (E 50S, Ferrari Medical, São Paulo, SP, Brazil); Olympus OTV-SC camera system (Olympus, Tokyo, Japan); Precision larynx rigid telescope (Precision 8mmx70°, Richards Medical, São Paulo, SP, Brazil), 70° angulation; MZ Medical external microphone system (MZ Medical Products, São Paulo, SP, Brazil); Sony TV monitor model PVM-2053MD (Sony Corporation, Tokyo, Japan). All videos were backed up in a database, using a MyGica video recorder (MyGica, Shenzhen, China). (...truncated)