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Paradoxical movements of the epiglottis--a rare cause of respiratory obstruction and its surgical treatment/Paradoksalni pokreti epiglotisa--redak uzrok respiratorne opstrukcije i njeno hirursko lesenje.

Introduction

A hanging or soft epiglottis may cause breathing disorders, which are often misinterpreted as asthma attacks or paradoxical vocal fold movement. Misinterpretations of the problem may lead to wrong treatment [1, 2]. Not only the hanging or soft epiglottis but its paradoxical movements can cause breathing disorders as well. The aim of this paper was to present a rare disorder of epiglottis function as a cause of breathing disorder and a manner of its solution.

Case Report

A 59-year-old male patient was referred from the General hospital for breathing disorders in the form of short cessations of breathing, which started two months after a cardiac surgical intervention. He could not tolerate even a slight physical effort.

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Indirect laryngoscopy and video endoscopy performed with a rigid endoscope indicated that the epiglottis was slightly lowered to the laryngeal inlet. During examination and request for repeated phonation of the vowel "e", the epiglottis descended even more and blocked the view of the larynx. The breathing ceased for a short time, and the arytenoid mucous membrane sank towards the lumen of the larynx (Figures 1 and 2). Repeated examinations showed that during respiration and phonation the epiglottis acted as a flap, occasionally closing the lumen of the larynx. It was concluded that it was the paradoxical movements of the epiglottis, but the cause remained unknown. The patient was recommended a surgical treatment. During admission for the operative treatment, the disorders increased.

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After admission to the Department, a subtotal resection of the epiglottis was performed with an argon plasma scalpel under general endotracheal anesthesia, using directoscopy of the larynx. In the postoperative course, a minor infection of the resected epiglottis developed, which was treated with antibiotic therapy. At the time of the first check-up, after three weeks, the patient was without any difficulties. Video endoscopy performed by a rigid endoscope was repeated. The examination showed a small remaining part of the epiglottis. There were no paradoxical movements of vocal folds; the left vocal fold was shorter, with a loose edge, and the posterior region of the glottis tilted to the left in phonation (Figures 3 and 4). The resulting conclusion was that the cause of the patient's discomfort might have been paresis of the left laryngeal nerve. The patient reported no breathing disorders three months after the operation.

Occasionally, he aspirated a small amount of liquid. The patient continued to perform his everyday activities without any difficulties.

Discussion

Paradoxical movements of the epiglottis probably result from the damaged upper laryngeal nerve. Roy et al. [3] studied the larynx behavior on an in vivo model after transitory unilateral paresis of the outer branch of the upper laryngeal nerve. They identified a deviation of the stalk of the epiglottis and axial rotation of the anterior/posterior commissure in response to the vocal requirements. The hanging epiglottis may be the reason for urgent intubation or tracheostomy [1]. The flat and thin epiglottis may cause complications during intubation by interfering with the vestibule of the larynx [4].

The paradoxical movements of the epiglottis as well as the tilting position of the glottis during phonation in the patient presented in this paper may have resulted from the damage of the upper laryngeal nerve. The exact cause of its damage cannot be established since the disorders occurred two months after intubation and cardiac surgery.

Although the bad general condition of patients, particulary bad respiratory function is contraindication for supraglottic surgery [5] surgical treatment of soft or hanging epiglottis enables significant reduction of airway obstruction. Partial or total resection of the epiglottis and the V resection are reliable methods which provide a good therapeutic result [2, 6]. Subtotal resection by argon plasma scalpel resulted in termination of breathing disorders in the patient described in this paper, and it enabled him to continue his normal everyday activities.

Conclusion

Paradoxical movements of the epiglottis are a rare cause of breathing disorders. Resection of the epiglottis, which was presented in this case study, provides a good therapeutic result.

The paper has been received: 16. I 2014.

The paper has been reviewed: 31. III 2014.

The paper has been accepted for publication: 2. IV 2014.

BIBLID.0025-8105:(2014):LXVII:7-8:252-254.

DOI: 10.2298/MPNS1408252C

References

[1.] Yano T, Hashimoto M, Kouchi A. Two cases of flaccid epiglottis. Masui. 2005; 54(5):500-3.

[2.] Kanemaru S, Kojima H, Fukushima H, Tamaki H, Tamura Y, Yamashita M, et al. A case of floppy epiglottis in adult: a simple surgical remedy. Auris Nasus Larynx. 2007; 34(3):409-11.

[3.] Roy N, Barton ME, Smith ME, Dromey C, Merrill RM, Sauder C. An in vivo model of external superior laryngeal nerve paralysis: laryngoscopic findings. Laryngoscope. 2009; 119(5):1017-32.

[4.] Ikegami N, Kikuchi A, Tamai S. Epiglottic prolapse induced by lighted stylet tracheal intubation. J Anesth. 2011; 25(2):294-7.

[5.] Petrovic Z. Results of supraglottic partial horizontal laryngectomy. Med Pregl. 2003; 56(11-12):568-70.

[6.] Oluwasanmi AF, Mal RK. Diathermy epiglottectomy: endoscopic technique. J Laryngol Otol. 2001; 115(4):289-92.

Karol V. CANJI (1), Slobodan M. MITROVIC (1) and Vera M. BELJIN (2)

Clinical Center of Vojvodina, Novi Sad Department of ear, nose and throat diseases (1) General hospital, Vrsac, Ear, nose and throat ward (2)

Corresponding Author: Dr Karol Canji, Klinicki centar Vojvodine, Klinika za bolesti uva, grla i nosa, 21000 Novi Sad, Hajduk Veljkova 1-7, E-mail: canjikarol@gmail.com
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Title Annotation:Case report/Prikaz slucaja
Author:Canji, Karol V.; Mitrovic, Slobodan M.; Beljin, Vera M.
Publication:Medicinski Pregled
Article Type:Case study
Date:Jul 1, 2014
Words:906
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