European Archives of Oto Rhino Laryngology 2021-03-01

Topical Collection: Sleep apnea syndrome: from the pathogenesis to the last therapies

Publication date 01-03-2021


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Acknowledgement to referees 2020

Publication date 01-03-2021


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Coagulation of posterior cricoarytenoid muscles for abduction spasmodic dysphonia

M Samaha,M Remacle

Publication date 01-03-2021


Introduction Spasmodic dysphonia (SD), a form of focal dystonia, has been defined as a neurogenic, task-specific disorder characterized by abrupt spasms of intrinsic laryngeal muscles that result in phonatory breaks.
There are three classic types of SD: adductor SD, abductor (ABSD) and mixed SD. Compared with the more common adductor form, treatment of ABSD with botulinum toxin injection is related to a shorter efficacy and improvement in only about 70% of patients Blitzer et al. in Laryngoscope 108:1435–1441, 1998. Moreover, due to the possible loss of efficacy over time or patient refusal for repeated injections, surgical solutions for permanent or at least long-term results must be considered. Method The surgical technique we propose is based on transoral bilateral posterior cricoarytenoid muscle (PCA) coagulation by radiofrequency (Celon, pro surg 250-T30, Olympus, Germany, 10 W, in 3 spots, each side) under a microscope or rigid scope control. The procedure is performed in two sessions distant of 2–3 weeks to avoid the risk of bilateral vocal fold temporary paralysis in adduction. A 52-year-old female patient with no audible voicing, resistant to botulinum toxin and after failure of relaxation thyroplasty type III according to lssihki Saito et al. in Case Rep Otolaryngol 2018:4280381, 2018 showed an improvement of the Voice Handicap Index (VHI-10) from 35/40 to 19/40. The patient was rated G2R3B2A1S2 according to GRABS scale. Conclusion PCA coagulation for ABSD is a safe and reusable surgical option. It is less invasive than other techniques described before. To the best of our knowledge, this technique was never reported before in this type of SD.

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Post-COVID-19 paradoxical vocal fold movement disorder

JR Lechien,MP Circiu,L Crevier-Buchman,S Hans

Publication date 01-03-2021


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Benefits in noise from sound processor upgrade in thirty-three cochlear implant users for more than 20\xa0years

I Mosnier,O Sterkers,Y Nguyen,G Lahlou

Publication date 01-03-2021


Purpose Some oldest patients rehabilitated with a cochlear implant more than 20 years ago could still be upgraded with new generations of speech processor (SP). The aim of this study was to show the benefit of a recent generation of SP in this population. Methods A monocentric prospective study was designed to evaluate the performance of 33 ancient CI22M users implanted between 1989 and 1997 and upgraded with the late compatible sound processor CP900. Performance was evaluated in quiet and noise with Framatix, an automated adaptative test. Results Performance using Framatix significantly improved with the CP900, with a decrease of the median speech perception threshold of 6 dB in quiet (p < 0.05) and 5,3 dB in noise (p < 0.0005). No subjective benefit using the APHAB questionnaire was observed. Conclusion Upgrading of cochlear implant recipients who were implanted more than 20 years ago with recent compatible and new technological SP provide benefit in speech recognition in noise.

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Post-intubation tracheal stenosis in COVID-19 patients

F Mattioli,A Marchioni,A Andreani,G Cappiello,M Fermi,L Presutti

Publication date 01-03-2021


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Explosion in hearing aid demands after Covid-19 outbreak curfew

S Ertugrul,E Soylemez

Publication date 01-03-2021


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Topographic anatomy of the ınternal branch of the superior laryngeal nerve

EM Güven,K Karacan,M Güven,H Elden,M Özçelik Korkmaz

Publication date 01-03-2021


Purpose The aim of this study was to investigate the surgical and topographical anatomy of the internal branch of the superior laryngeal nerve (ibSLN) in laryngectomy patients. Methods Patients aged 36–90 years old who underwent a total laryngectomy operation with a diagnosis of laryngeal carcinoma participated in the study. Fifteen patients who underwent a total laryngectomy operation between June 2015 and November 2016 were included in the study. A total of 29 superior laryngeal nerves (SLN) of 15 patients were studied. The position of the nerve was photographed before the thyrohyoid membrane (THM) was passed during dissection. The relationship and course of the ibSLN with respect to the superior laryngeal artery (SLA) were observed. The distance to adjacent formations and branching variants were examined along the course of the nerve. Results Of the total 29 ibSLN, 17 were divided into three branches and 12 into two branches. In all cases except for one, the ibSLN course after piercing the THM was determined. The ibSLN penetrated the THM at a mean of 12.0 ± 2.61 mm (6–16 mm) from the superior border of the thyroid cartilage. The ibSLN penetrated the THM with a mean distance of 9.34 ± 1.65 (6–12) mm from the inferior border of the hyoid bone. Conclusion Our study demonstrated the surgical and topographical features of the ibSLN with respect to the THM, and provided a more precise knowledge of its anatomy in laryngectomy patients. It thus may help head and neck surgeons identify this nerve.

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Management of loco-regionally advanced squamous laryngeal cancer in elderly patients

S Cavalieri,E Orlandi,E Ivaldi,C Bergamini,S Alfieri,NA Iacovelli,R Ingargiola,C Resteghini,F Platini,G Apollonio,T Beninato,F Incandela,W Fontanella,L Bresciani,L Giannini,C Piazza,L Licitra,LD Locati

Publication date 01-03-2021


Purpose To describe the management and outcomes of loco-regionally advanced (stages III-IV) laryngeal cancer (LRALC) in elderly patients. Methods Clinical records of 88 LRALC patients treated at our Institution from 2002 to 2017 were retrospectively reviewed.
Patients were divided in 2 subgroups: age > 65 years (elderly) and age ≤ 65 years (controls). Survivals were estimated with Kaplan–Meier method and compared with log-rank test, multivariate analysis were performed with Cox proportional hazard methods. Results Eighty-eight LRALC patients were included: 45 elderly and 43 controls. Median follow-up was 55.3 months. Median age was 66 years (range 41–84) in the overall population, 72 years (range 66–84) in the elderly cohort. The majority (98%) of elderly patients had at least one comorbidity (ACE27 1–3), while ACE27 was 0 in 37% of controls (p = 0.0001). ECOG PS was 0 in 42% of elderly vs 79% of controls (p = 0.0029). Clinical stage (TNM eighth edition) was III in 67%, IVA in 22% and IVB in 11%. Treatment consisted in total laryngectomy (TL) in 55%, chemo-radiation in 29%, exclusive radiotherapy in 9%, and conservative surgery in 7%. In elderly patients 2-year disease-free and overall survivals were 58% and 74%, respectively. Multivariate analysis performed on the overall group of 88 patients showed that age (HR 1.07, p = 0.0006) and TNM (for both 7th and 8th Editions HR 0.27 for stage III vs IV, p = 0.0005) maintained an independent statistical significant association with OS. Conclusions In this monocentric cohort, age and TNM confirmed their independent prognostic role in LRALC patients. Organ-preservation is still an unmet need in a significant portion of elderly patients.

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The imaging anatomy of ethmomaxillary sinus and its impact on chronic rhinosinusitis

F Zhou,C Cao,W Fan,L Tan,P Liu,H Lv,Y Xu

Publication date 01-03-2021


Purpose The aim of this study was to investigate the pneumatization degree of ethmomaxillary sinus (EMS) and adjacent structures, and its impact on chronic rhinosinusitis (CRS). Methods A retrospective analysis of paranasal sinus CT scans of 996 patients was conducted. The maximum vertical diameter of EMS in the coronal plane was measured, allowing EMS to be classified, and its impact on ipsilateral CRS were examined. Results The prevalence of EMS was 11.9%. The maximum vertical diameter of EMS in the coronal plane ranged from 3.68 to 28.76 mm with a mean (± SD) of 11.32 ± 5.12 mm. The prevalence rates of EMS in CRS sides and non-CRS sides were 12.5% and 9.3%, respectively, which was significantly different (χ2 = 4.495; p < 0.05). The difference in prevalence between the three types of EMS in ipsilateral CRS was statistically significant (χ2 = 6.733; p < 0.05). The difference in Lund–Mackay (LM) score of ipsilateral CRS between the three types showed no statistically significant difference (H = 4.033; p > 0.05). Conclusion EMS is a common anatomical variation with marked individual differences in shape and pneumatization degree. A higher degree of EMS pneumatization may contribute to the occurrence of CRS; this should be investigated before surgery.

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Elective tracheostomy during COVID-19 outbreak: to whom, when, how? Early experience from Venice, Italy

T Volo,P Stritoni,I Battel,B Zennaro,F Lazzari,M Bellin,L Michieletto,G Spinato,C Busatto,D Politi,R Spinato

Publication date 01-03-2021


Purpose The need for prolonged invasive mechanical ventilation in COVID-19 patients is placing the otorhinolaryngologist in front of an increasing request for tracheostomy. Nowadays, there is uncertainty regarding the timing of tracheostomy, the prognosis of these patients and the safety of healthcare workers. The aim of this study is to evaluate the efficacy and safety of tracheostomy placement in patients with COVID-19. Methods A retrospective cohort study on 23 COVID 19 patients, to analyse the timing of tracheostomy, the risk factors associated with in-hospital death and the infection of the involved health care workers. Early tracheostomy was defined as ≤ 10 days and late ones > 10 days. Results The mortality rate of COVID-19 patients admitted to ICU that underwent tracheostomy was 18%. The overall mortality of patients admitted to ICU was 53%. The univariate analysis revealed that early tracheostomy, SOFA score > 6, and D-dimer level > 4 were significantly associated with a greater risk of death. At the multivariate analysis SOFA score > 6 and D-dimer level > 4 resulted as significant factors for a higher risk of death. No health care workers associated with tracheostomy are confirmed to be infected by SARS-CoV2. Conclusion We suggest to wait at least 14 days to perform tracheostomy. In patients with SOFA score > 6 and D dimer > 4, tracheostomy should not be performed or should be postponed. Optimized procedures and enhanced personal protective equipment can make the tracheostomy safe and beneficial in COVID-19 patients.

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Maximum isometric tongue force in patients with obstructive sleep apnoea

R Birk,BA Stuck,JT Maurer,A Schell,CE Müller,B Kramer,S Hoch,JU Sommer

Publication date 01-03-2021


Background Obstructive sleep apnea (OSA) is a sleep disorder with a prevalence of 9–38%. The underlying pathology in OSA is a collapse of the upper airway. Especially in more severely affected patients, this collapse is often located at the level of the tongue base. Therefore, various implantable systems (anchors and ligament techniques) were developed to prevent or overcome this collapse. These systems are exposed to various forces. Different models have been developed to measure these forces and data comparing forces in healthy individuals with OSA patients are rare. Purpose Purpose of the study was to evaluate possible differences in tongue forces between healthy individuals and patients with OSA. Method To evaluate maximum isometric tongue forces, we conducted a matched pair design study including 20 healthy individuals and 20 patients suffering from OSA. Maximum isometric tongue forces were measured in an anterior/posterior direction with the help of self-designed new device that clamps the tongue. Results We could show that the maximum isometric force does not differ significantly in healthy individuals (10.7 ± 5.2N) from patients with OSA (14.4 ± 6.3N). Conclusion Currently there are no indications that maximum isometric tongue force does differ in healthy individuals and patients with OSA. Higher, as well as lower, tongue forces in patients with OSA seem not to differ from healthy subjects and therefore may not be needed to consider, in the development of tongue management devices, for OSA patients.

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How applicable is the TNM 8 staging for human papillomavirus (HPV)\xa0related oropharyngeal squamous cell carcinoma (OPSCC) to a UK population of 106 patients?

T Bradish,H Fisher,V Paleri,M Robinson,D Meikle,C Kelly,J O'Hara

Publication date 01-03-2021


Purpose TNM8 introduced a new staging system for HPV positive oropharyngeal squamous cell carcinoma (OPSCC). This study aimed to investigate whether the changes made in TNM8 offer the perceived benefit in prognostication when compared to TNM7 in a specific patient population in the North East of England. Methods A retrospective cohort comparison study of all patients with HPV positive OPSCC (n = 106) through the Newcastle Head and Neck MDT between January 2012 to December 2014. Overall survival (OS) and Disease specific survival (DSS) data at 3 years was gathered for both TNM7 and TNM8. Log rank test was used to compare survival curves. Harrell’s C-index adjusted for age and smoking status was used to assess prognostic ability of the two staging methods. Results TNM8 downstages disease (TNM7 stage IV patients n = 74, TNM8 stage IV patients n = 2) but gives a more even distribution of patients across disease stages. Survival for TNM8 stage II and III is similar. In our small cohort, the log-rank test detected differences in OS between stages for both scoring methods (TNM7 p = 0.006, TNM8 p < 0.001) and similarly for DSS (TNM7 p = 0.001, TNM8 p < 0.001). Harrell’s C-index was similar for both models for OS (TNM7 0.71, TNM8 0.71) and DSS (TNM7 0.74, TNM8 0.70). Conclusion TNM8 downstages disease and prognosticates well for stage I disease but does not differentiate between stage II and III disease when compared to TNM7. Further adaptation is required to address this to make TNM8 a more accurate prognostic tool.

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Chemosensory dysfunction in COVID-19 out-patients

MJ Rojas-Lechuga,A Izquierdo-Domínguez,C Chiesa-Estomba,C Calvo-Henríquez,IM Villarreal,G Cuesta-Chasco,M Bernal-Sprekelsen,J Mullol,I Alobid

Publication date 01-03-2021


Background Since the outbreak in China due to coronavirus disease 2019 (COVID-19) various studies have been published describing olfactory and gustatory dysfunction (OGD). Objective The aim was to investigate the frequency and severity of OGD in SARS-CoV-2 (+) out-patients compared to controls with common cold/flu like symptoms and two negative RT-PCR. Methods A multicenter cross-sectional study on SARS-CoV-2-positive out-patients (n = 197) and controls (n = 107) from five Spanish Hospitals. Severity of OGD was categorized by visual analogue scale (VAS). Frequency and severity of the chemosensory impairment were analyzed. Results The frequencies of smell (70.1%) and taste loss (65%) were significantly higher among COVID-19 subjects than in the controls (20.6% and 19.6%, respectively). Simultaneous OGD was more frequent in the COVID-19 group (61.9% vs 10.3%) and they scored higher in VAS for severity of OGD than controls. In the COVID-19 group, OGD was predominant in young subjects 46.5 ± 14.5 and females (63.5%). Subjects with severe loss of smell were younger (42.7 years old vs 45.5 years old), and recovered later (median = 7, IQR = 5.5 vs median = 4, IQR = 3) than those with mild loss of smell. Subjects with severe loss of taste, recovered later in days (median = 7, IQR = 6 vs median = 2, IQR = 2), compared to those with mild loss. Conclusion OGD is a prevalent symptom in COVID-19 subjects with significant differences compared to controls. It was predominant in young and females subjects. Stratified analysis by the severity of OGD showed that more than 60% of COVID-19 subjects presented a severe OGD who took a longer time to recover compared to those with mild symptoms.

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Changes of incudostapedial joint angle in stapedotomy: does it impact hearing outcomes?

Y Fang,K Zhang,LJ Ren,JJ Lamb,R Hong,Y Shu,B Chen

Publication date 01-03-2021


Purpose The aims of this article are: (1) is there an ideal incudostapedial joint (ISJ) angle after stapedotomy? (2) is there any difference between pre- and postoperative ISJ angle? and (3) what is the significance of the ISJ angle in postoperative hearing outcomes? Methods Forty six ears from 39 different adult patients (28 women and 11 men; 21 left and 25 right ears) with a mean age of 39 years with clinical otosclerosis who underwent stapedotomy between May 2017 and May 2019 were retrospectively registered, including seven bilateral surgery cases. ISJ angle and intravestibular depth of the stapes prosthesis were measured from multiple planar reconstruction-computed tomography images and the length of the prosthesis was measured during surgery. Relationships between the ISJ angle parameters and postoperative hearing outcomes and parameters of the prosthesis were analyzed. Results The mean ISJ angle was 93.3° ± 8.8° preoperatively and 101.9° ± 6.3° postoperatively, increasing by 8.6° during stapedotomy (p < 0.01). There were weak and negative correlations between ISJ angle changes and postoperative air conduction gains at frequencies ≤1 k Hz and bone conduction gains at 0.5 k Hz. When the postoperative ISJ angle changed more than 20°, the success rate of the procedure decreased to 0%. Conclusion The stapedotomy operation increased the ISJ angle. The success of postoperative auditory outcomes had more to do with the ISJ angle change than the value of the angle itself, indicating there is no universal ideal ISJ angle that surgeons should aim for during stapedotomy.

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The novel indicators of moderate to severe sleep apnea: fibrinogen to albumin ratio vs. CRP to albumin ratio

Publication date 01-03-2021


Purpose This study aimed at investigating the association of severity of obstructive sleep apnea with the markers of inflammation as fibrinogen to albumin ratio and C-reactive protein to albumin ratio. Methods We included 126 patients admitted to sleep disorders outpatient clinic. We constituted four groups by reference to the apnea–hypopnea index (mild-moderate-severe sleep apnea and control group). We investigated the difference of white blood cell, fibrinogen to albumin ratio, C-reactive protein to albumin ratio, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, and hemoglobin among the groups. Results Neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, and hemoglobin did not significantly differ among four groups (p = 0.39, p = 0.06, and p = 0.31, respectively). A significant difference of fibrinogen to albumin ratio and C-reactive protein to albumin ratio was evident among four groups (p < 0.001). Fibrinogen to albumin ratio and C-reactive protein to albumin ratio did not significantly differ between the mild sleep apnea and control groups (p = 0.65, and p = 0.85, respectively), but were significantly greater in moderate sleep apnea group compared with the control group (p < 0.001 and p = 0.001, respectively). Also, fibrinogen to albumin ratio and C-reactive protein to albumin ratio were significantly greater in the severe sleep apnea group compared with the control group (p < 0.001). Fibrinogen to albumin ratio and C-reactive protein to albumin ratio did not significantly differ between the severe sleep apnea and moderate sleep apnea groups (p = 0.49, and p = 0.58, respectively). Conclusion Higher fibrinogen to albumin ratio and C-reactive protein to albumin ratio may be predictive of inflammation in patients with moderate-to-severe sleep apnea.

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Predicting outcome of velopharyngeal surgery in drug-induced sleep endoscopy by traction velum

M Zhu,S Gong,J Ye,Y Wang,X Bai,KA Peng

Publication date 01-03-2021


Background Outcomes of surgical management of obstructive sleep apnea–hypopnea syndrome (OSAHS) can be difficult to predict preoperatively. Aims/objectives To study the effect of applying traction to the velum during drug-induced sleep endoscopy (DISE) in OSAHS patients, and to describe the use of traction velum in predicting surgical success. Materials and methods 41 adult surgical patients with OSA (Friedman tongue position II and III) were evaluated by DISE. All patients subsequently underwent velopharyngeal surgery in the form of uvulopalatopharyngoplasty with tonsillectomy plus barbed reposition pharyngoplasty. Results Surgical responders (n = 26, 63.4%) and nonresponders (n = 15, 36.6%) demonstrated no significant differences with regard to preoperative AHI, age, sex, body mass index, and mean/lowest O2 saturation. Responders had a marked decrease in desaturation events (2.96 vs 0.03, p < 0.001) and percentage change in number of desaturation events before/after traction velum (56.7 vs 4.5, p < 0.001). Regression analysis revealed that reduction in mean desaturation events, with traction velum, by a percentage > 26.8% (odds ratio OR 1.046; 95% confidence interval CI 1.018–1.075; p = 0.001) was the only independent predictor of surgery success. Conclusions and significance OSAHS patients’ velopharyngeal surgical outcome can be predicted by measuring the percentage change in the number of oxygen desaturation events before and after traction velum in DISE.

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Expansion sphincter pharyngoplasty: analyzing the technique based on anatomy

Publication date 01-03-2021


Purpose The purpose of this study is to evaluate the effect of the different surgical techniques of expansion sphincter pharyngoplasty (ESP) on the dimensions of the oropharyngeal airway. Methods The techniques that were evaluated included the preservation and transection of the palatopharyngeus (PP) and superior pharyngeal constrictor (SPC) muscle attachment and transposition of the PP muscle to the hamulus of the medial pterygoid plate and the palatal musculature. Surgical techniques were applied in twenty half heads. Results The preservation of the PP–SPC attachment inhibited the transposition of the PP muscle to the hamulus and resulted in comparable enlargement in the medial–lateral dimension in the oropharyngeal airway when the PP muscle was transposed to the palatal musculature. After transection of the PP–SPC attachment, significant enlargement was observed in anterior–posterior and medial–lateral directions in the oropharyngeal airway when the PP muscle was transposed both to the hamulus and the palatal musculature. The distances measured after both the transposition techniques were similar. Conclusion The present study is a basic study demonstrating how different techniques of ESP affect the position of the soft palate. The PP–SPC attachment can be transected in the patients with anterior–posterior palatal and lateral wall collapse to pull the soft palate anteriorly in addition to prevent the lateral wall collapse. The PP–SPC attachment can be preserved in the patients with only lateral wall collapse. Nevertheless, the clinical consequences of these static changes need to be evaluated in clinical studies.

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Predictive factors of severity and persistence of oropharyngeal dysphagia in sub-acute stroke

A De Stefano,F Dispenza,G Kulamarva,G Lamarca,A Faita,A Merico,G Sardanelli,S Gabellone,A Antonaci

Publication date 01-03-2021


Purpose This study aims to understand the factors contributing to the severity of oropharyngeal dysphagia and its persistence in the sub-acute phase of stroke. Methods We retrospectively collected the data of all the patients suffering from a stroke in the last year. The severity of stroke was reported according to the NIHSS score. All the patients were evaluated with the Dysphagia Risk Score and with a FEES. We classified the Dysphagia Risk Score and FEES results using the PAS score and ASHA-NOMS levels. The data were analysed statistically with ANOVA test, Student’s t test and Pearson’s correlation coefficient. Results A series of 54 patients were evaluated. The ANOVA test did not find any difference in the mean score of Dysphagia Risk Score, PAS and ASHA-NOMS when compared with the brain area of stroke. An NIHSS at hospital admission (stroke unit) of more than 12 was predictive of ASHA-NOMS score 1–4 after 60 days (p < 0.05). A PAS score between 6 and 8 at first FEES evaluation was predictive of poor (1–4) ASHA-NOMS score after 60 days (p < 0.01). A moderate positive linear correlation was found between NIHSS score and both PAS (r 0.65) and Dysphagia Risk Score (r 0.50); a moderate negative linear correlation was recorded between NIHSS and ASHA-NOMS (r  − 0.66) scores. Conclusion In the sub-acute phase of stroke, the predictive factors of persistent dysphagia are not linked to the damaged neuroanatomical region and others factors such as NIHSS value and high PAS score seem more useful.

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Investigation of the serum vitamin D level in infants followed up with the diagnosis of laryngomalacia: a case–control study

HB Bozkurt,M Çelik

Publication date 01-03-2021


Objective The possible etiological relationship of the vitamin D with laryngomalacia is unclear. The aim of the study was to demonstrate the relationship between laryngomalacia and vitamin D levels. Methods Twenty-three non-syndromic babies under the age of 1 year who were diagnosed with laryngomalacia were included in the study group. Forty healthy babies were included in the control group. The detailed anamnesis was obtained and a complete systemic physical examination, a flexible endoscopic laryngeal examination, and laboratory tests calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), parathormone (PTH), alanine transaminase (ALT), aspartate transaminase (AST), blood urea nitrogen (BUN), creatinine (Cre), and 25-hydroxy vitamin D (25-OH D) were performed in all patients. All laboratory tests of the groups were compared. Results It was observed that there was no significant difference in the parameters that could affect vitamin D levels, namely type of feeding, vitamin D supplement intake, and the season when the serum sample was taken (p > 0.05). The vitamin D level was significantly lower (p = 0.003, p < 0.05) and the P and ALP levels were significantly higher (p = 0.016 and p = 0.001, respectively; p < 0.05) in the laryngomalacia group. Although the correlation between vitamin D and PTH was not statistically significant according to the Pearson correlation analysis, it was lower in the laryngomalacia group compared to the control group (p = 0.381, p > 0.05). Conclusion In this study, it was observed that the vitamin D levels were lower in infants with laryngomalacia compared to the control group. We consider that vitamin D deficiency may be a factor in the etiology of laryngomalacia with a yet-to-be-clarified etiology.

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