|Year : 2020 | Volume
| Issue : 2 | Page : 73-77
Laryngeal pathology requiring microlaryngoscopy a retrospective descriptive study of a single tertiary center in bahrain
Maryam Isa Khalifa1, Fatema Mohamed Alasfoor1, Tasabeeh Ahmed Qareeballa Yousif1, Fatema Sayed Ali Mohamed Alhashimi2
1 Department of Otolaryngology and Head and Neck Surgery, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
2 Department of Hisotpathology, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
|Date of Submission||21-Apr-2020|
|Date of Decision||06-May-2020|
|Date of Acceptance||10-Jun-2020|
|Date of Web Publication||30-Dec-2020|
Dr. Maryam Isa Khalifa
House 600, Road 2413, Block 424, Jidhafs
Kingdom of Bahrain
Source of Support: None, Conflict of Interest: None
Background: Laryngeal pathologies are commonly encountered in otolaryngology practice, and more benign lesions have been described than malignant ones. Microlaryngoscopy and biopsy are used to obtain a definite diagnosis in such cases. Aim: The aim was to study laryngeal pathologies requiring microlaryngoscopy in our tertiary care center during the period of 2014–2018. Study Design: This was a retrospective cohort study. Materials and Methods: Data were retrospectively extracted from the records of patients who had a suspected diagnosis of laryngeal pathology based on history and clinical examination and eventually underwent microlaryngoscopy procedures under general anesthesia. Results: There were 51 participants who underwent 58 microlaryngoscopic examinations. Males accounted for 61% of the participants. The mean age was 45 years. The most frequently presenting complaint was voice change. Benign lesions were more common than malignant ones. The most frequently described lesions were vocal fold polyps. Conclusion: We believe this is the first epidemiologic study to investigate laryngeal pathologies requiring microlaryngoscopy in Bahrain. The study provides insight into our population presenting with laryngeal pathology requiring microlaryngoscopy and could provide a basis for future research.
Keywords: Laryngeal pathology, microlaryngoscopy, prevalence
|How to cite this article:|
Khalifa MI, Alasfoor FM, Qareeballa Yousif TA, Alhashimi FS. Laryngeal pathology requiring microlaryngoscopy a retrospective descriptive study of a single tertiary center in bahrain. Saudi J Otorhinolaryngol Head Neck Surg 2020;22:73-7
|How to cite this URL:|
Khalifa MI, Alasfoor FM, Qareeballa Yousif TA, Alhashimi FS. Laryngeal pathology requiring microlaryngoscopy a retrospective descriptive study of a single tertiary center in bahrain. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2022 Dec 4];22:73-7. Available from: https://www.sjohns.org/text.asp?2020/22/2/73/305459
| Introduction|| |
Laryngeal pathology is common in otolaryngology practice. A noticeable increase in the number of laryngeal biopsies has been described over the last decade. Benign lesions of the larynx are more common than malignant ones. The most encountered lesions are vocal fold polyps, nodules, cysts, tuberculosis of the larynx, laryngocele, laryngeal web, epiglottic cysts, and subglottic hemangioma. The sites involved are the vocal folds, arytenoids, and epiglottis.
Malignancies are less common pathologies, and most of them are squamous cell carcinoma (SCC). Dysplasia is another well-known precancerous condition that is encountered and needs to be managed. Laryngeal lesions develop secondary to factors related to laryngeal trauma, such as vocal abuse, smoking, alcohol intake, and laryngopharyngeal reflux (LPR), especially in young people and professional voice users.,,,
Various age-related incidences have been described in the literature, but people in their 30s and 40s tend to be more affected by benign lesions., People who are 60 years old or more tend to have dysplasia and malignancies. Sex-related incidence is another discussed topic. Some studies have reported that voice disorders are more common in females,, but others report that they are more common in males.,,
The aim of this study is to investigate laryngeal pathologies that required microlaryngoscopy in our tertiary care center during the period of 2014–2018. We describe the individuals' age, gender, characteristics, presenting symptoms, duration of illness, and type and site of lesions.
| Materials and Methods|| |
This retrospective cohort study was conducted in the otolaryngology and head-and-neck department of our tertiary care center. No sample size was calculated since the intent was to conduct a retrospective descriptive study of all individuals who fit the inclusion criteria. We identified patients who underwent microlaryngoscopy in the specified period of 2014–2018 through inpatient admission, operating theater, and histopathological specimen records.
The time frame was chosen to coincide with the introduction of electronic health records in the hospital for ease of information extraction. Patients who fit the inclusion criteria were enrolled. A retrospective chart review of the relevant clinical and pathological data was performed. Data were obtained from the electronic health records from outpatient clinic visits, inpatient admissions, operative notes, and histopathology specimen reports. We based our diagnosis and the following discussion on the histopathology examination of specimens postoperatively to avoid issues due to poor documentation of preoperative clinical findings, variability in the preoperative examination tools utilized (indirect laryngoscopy vs. flexible nasoendoscopy vs. rigid laryngoscopy), incomplete intraoperative reports describing the lesions, and discrepancy between the final histopathological diagnosis and both preoperative and intraoperative diagnoses.
Since we have no available facilities to test for LPR, we opted for gastroesophageal reflux disease (GERD) evaluation in the assessment of associated comorbidities. In our center, GERD is usually diagnosed using a double-contrast barium swallow study, where the patient ingests liquid barium contrast medium, and gas granules are filmed in certain transitions of body positions. A radiologist describes the volume of contrast material going above the gastroesophageal junction and the anatomic level that it reaches.
| Subjects|| |
Our inclusion criterion was all patients who underwent a microlaryngoscopy procedure under general anesthesia in the stated time frame. We employed no exclusion criteria. A total of 51 participants who underwent 58 microlaryngoscopic procedures were included in the study. Each candidate received a study identification number to maintain the confidentiality of the data. The following parameters were noted for each candidate:
- Demographic data: Age, gender, and occupation
- Comorbidities: Mainly GERD
- Smoking and alcohol consumption status
- History of illness: Symptoms, duration, and preoperative examination findings
- Microlaryngoscopy under general anesthesia
- Histopathologic examination.
Data were handled using MS Office Excel and analyzed using the statistical software Stata version 15.1 (Stata Corporation, College Station, Texas, USA). Descriptive statistical terms were used to summarize the data.
The Secondary Care Research Sub-Committee of Bahrain's Ministry of Health provided ethical approval for this research before its commencement.
| Results|| |
There were a total of 51 participants who underwent 58 microlaryngoscopic procedures. There were 31 males (61%) and 20 females (39%). Their mean age was 45 ± 15 years, with a range of 4–79 years [Table 1].
There were ten professional voice users (20%), seven teachers, one driving instructor, one salesman, and one Quran reciter. GERD was documented in 20 participants (39%) according to the barium swallow examination. There was a lack of proper documentation of smoking and alcohol consumption status in our participants' records. There were 12 participants who were smokers (24%), 11 participants who were ex-smokers (22%), 1 participant who reported passive smoking (2%), and 9 participants who were nonsmokers (18%). The remaining 18 participants (35%) had no documentation of their smoking status.
Even scarcer documentation was observed for alcohol consumption. Only one subject reported current alcohol consumption, and another reported previous alcohol consumption. There was no documentation for the other 49 subjects.
The most frequent presenting complaint was voice change in 48 participants (94%), followed by breathing difficulty in 3 participants (6%), swallowing difficulty or pain in 3 participants (6%), constitutional symptoms in 2 participants (4%), cough in 1 participant (2%), and foreign body sensation in 1 participant (2%). Only 39 of the 51 participants had a documented duration of symptoms. The duration of presenting symptoms ranged from 0.1 to 360 months, with a mean of 27 ± 67 months. The preoperative examination was mostly described as nonspecific laryngeal lesions in 18 participants (35%). Polyps were only described in 12 subjects (24%), cysts were found in 7 (14%), and nodules were found in 2 (4%). When these results were compared with the postoperative histopathology examination, only 15 participants (29%) had the same diagnosis [Table 2].
The purpose of the microlaryngoscopy procedure varied. There were five participants (10%) who only needed a diagnostic examination due to a lack of definitive preoperative findings. These participants were examined under general anesthesia, but no biopsy or surgical intervention was performed. There were 24 participants (47%) who had both an examination and a biopsy because their preoperative findings were nonspecific. Finally, there were 22 participants (43%) who had procedures for both diagnostic and therapeutic purposes because the observed lesions needed complete surgical excision [Table 3].
The most common site of origin of laryngeal lesions was the true vocal folds in 43 participants (84%), followed by the false vocal folds in 1 participant (2%), the epiglottis in 1 participant (2%), the vallecula in 1 participant (2%), and the arytenoids in 1 participant (2%). There were three participants with no lesions found intraoperatively (6%), and for one participant, no specific site was mentioned (2%).
Most of our study population had benign laryngeal lesions, which were seen in 32 participants (63%). There were malignant lesions in nine participants (18%), dysplasia in one participant (2%), nonconclusive biopsies in one participant (2%), and normal histopathology in two participants (4%). No biopsy was taken in six participants (12%).
The most frequent types of lesions were as follows: 18 laryngeal polyps (35%), 9 laryngeal nodules (18%), 7 SCC lesions (14%), 3 cysts (6%), 3 dysplasia lesions (6%), 3 chronic inflammatory changes (6%), and 1 papilloma (2%) [Table 4]. Some participants had histopathological findings of normal mucosa despite an abnormal microlaryngoscopic examination. Therefore, these participants had multiple microlaryngoscopic procedures: three participants (6%) had the procedure twice and two participants (4%) had it three times.
| Discussion|| |
There has been a significant increase in laryngeal biopsies during the last decade (approximately 25%). This is the first epidemiological study to investigate the practice of microlaryngoscopy in our center, so we have no baseline figures for comparison to determine whether there is a similar rising trend. However, we were able to identify a good number of procedures during the investigation period to investigate other variables.
Laryngeal pathologies presenting as voice disorders are reported to be more common in females by some studies, and males by others.,, A study investigating laryngeal pathologies in a Portuguese academic population in 2014 demonstrated that females were predominant among the population, with a mean age of 43 years. Mozzanica et al. stated that the majority of patients seeking voice therapy were females. Woo et al. found no difference in age or gender in a general South Korean population.
In our study, there were more males (61% of our population). However, the mean age was 44 years, which is similar to previous studies. Our categorized age groups showed that the majority of our participants were in their 30s, 40s, and 50s. These results are in concordance with other studies.,,,,,
It is worth noting that there were pediatric participants in our study since we did not exclusively include adults. Only two of them were younger than 12 years old. Both of them underwent examination under general anesthesia without any microsurgical intervention. One of them had a normal examination, and the other had a vocal fold nodule that did not require further intervention [Table 5]. This is the practice in our center, where generally, we only treat this age group under general anesthesia in cases of difficult or suspicious examination in the clinical setting to reach a diagnosis in the operating room.
|Table 5: Histopathology of lesion distribution according to age group, n (%)|
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There are certain precipitating factors related to the development of laryngeal lesions, such as exposure to irritants such as smoking,,, reflux laryngitis,, and voice abuse,,,,, which have been mentioned throughout the literature in patients with laryngeal pathologies. Our study data cannot be used to conduct a statistical assessment of associations in view of the limitations in the documentation of smoking and alcohol consumption status and the inability to document LPR with a gold standard diagnostic study. Nonetheless, the results demonstrated the presence of such characteristics in our participants.
Hoarseness of voice is the most common symptom presenting in patients with laryngeal disease.,,, A study examined laryngeal pathologies in professional voice users in Bahrain, and hoarseness of voice was found to be present in 91.5% of the participants, which is close to our results (94% of our participants). The mean time frame of presenting to the hospital in other studies ranged from 1 month to 2 years.,, In our study, the range was 0.1 months (3 days) to 360 months (30 years), with a mean of 27 ± 67 months. This indicates wide variability, which could be attributed to the variability in laryngeal pathologies and their degree of acuteness.
Vocal polyps or nodules are generally the most common lesions among patients presenting to otolaryngology practices with voice change.,,,,, In our study, vocal fold polyps were the most common diagnosis, thus matching the general expectation. Some studies have investigated the statistical association between the lesions and gender, but mostly, no statistically significant effects have been described.,, We stratified the lesions by gender and found a similar pattern of lesion distribution where polyps and nodules were the most common in females, while polyps were the most common in males, followed by SCC and nodules [Table 6].
|Table 6: Histopathology of lesion distribution according to gender, n (%)|
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When examining the subsites, we found that true vocal folds were the most affected site, accounting for 84% of our lesions. This is similar to the range of 44%–88% described in various studies.,, Benign lesions of the larynx are more common than malignant ones, which was observed in our participants. Another entity that needs to be mentioned is laryngeal dysplasia, which is premalignant and has a reported rate of progression to malignancy of 14% over 43.28 months. The incidence of laryngeal dysplasia was 6% in our study. However, we are not able to comment on its transformation if any due to the limited time frame of the study and the lack of follow up of our participants.
Limitations and recommendations
The main limitation that we faced was a lack of proper documentation of data in terms of patients' predisposing factors and clinical findings. Another limitation was related to the difficulty of acquiring older data from the time before the electronic health record system was set up, which limited the population size. We recommend that more effort be made in documenting patient data, especially predisposing factors such as smoking, alcohol consumption, and voice abuse. We also recommend preferably following known diagnosis codes when documenting clinical findings preoperatively and intraoperatively to facilitate future research efforts. Furthermore, patients should be re-examined closer to the day of microlaryngoscopy to confirm the persistence of the same clinical findings. This would help to avoid unnecessary procedures and exposure to general anesthesia in cases where a lesion might have ruptured or subsided in the time that has passed.
| Conclusion|| |
We studied the clinicopathological profiles of the laryngeal pathologies presenting to a tertiary health-care facility in Bahrain among patients requiring microlaryngoscopic procedures. We believe we are the first to provide such insight into our clinical practice. The results could form a basis for moving forward to further population-specific studies of possible correlations and outcomes in laryngeal pathologies in Bahrain. Further studies with larger scales and longer durations are required with adjustment for confounders for closer investigation of the possible associations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lim S, Sau P, Cooper L, McPhaden A, Mackenzie K. Laryngeal biopsies: Are we doing more, and why? A decade of results. J Laryngol Otol 2016;30:100-3.
Hegde MC, Kamath MP, Bhojwani K, Peter R, Babu PR. Benign lesions of larynx-A clinical study. Indian J Otolaryngol Head Neck Surg 2005;57:35-8.
Montgomery J, White A. A decade of laryngeal dysplasia in Paisley, Scotland. Eur Arch Otorhinolaryngol 2012;269:947-51.
Won SJ, Kim RB, Kim JP, Park JJ, Kwon MS, Woo SH. The prevalence and factors associate with vocal nodules in general population: Cross-sectional epidemiological study. Medicine (Baltimore) 2016;95:e4971.
Al Bareeq JM. Voice overuse and abuse among professional voice users. Bahrain Med Bull 2001;23:12-8.
Mozzanica F, Ginocchio D, Barillari R, Barozzi S, Maruzzi P, Ottaviani F, et al
. Prevalence and voice characteristics of laryngeal pathology in an Italian voice therapy-seeking population. J Voice 2016;30:774.e13-23.
Brinca L, Nogueria P, Tavares AI, Batista AP, Gonéalves IC, Moreno M. The prevalence of laryngeal pathologies in an academic population. J Voice 2015;29:130.e1-9.
Sharma M, Kumar S, Goel M, Angral S, Kapoor M. A clinical study of benign lesions of larynx. Int J Oral Health Med Res 2015;2:22-8.
Singhal P, Bhandari A, Chouhan M, Sharma MP, Sharma S. Benign tumors of the larynx: A clinical study of 50 cases. Indian J Otolaryngol Head Neck Surg 2009;61:26-30.
Bharathi MM, Selvam DK, Vikram VJ. MA study on non-malignant lesion of larynx. Int J Otorhinolaryngol Head Neck Surg 2018;4:655-8.
Woo SH, Kim RB, Choi SH, Lee SW, Won SJ. Prevalence of laryngeal disease in South Korea: Data from the Korea National Health and Nutrition Examination Survey from 2008 to 2011. Yonsei Med J 2014;55:499-507.
Qi X, Yu D, Zhao X, Jin C, Sun C, Liu X, et al
. Clinical experiences of NBI laryngoscope in diagnosis of laryngeal lesions. Int J Clin Exp Med 2014;7:3305-12.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]