Lingual thyroid causing dysphagia and dyspnoea. Case reports and review of the literature.

Lingual thyroid is a rare embryological anomaly and originates from failure of the thyroid gland to descend from the foramen caecum to its normal eutopic pre-laryngeal site. The ectopic gland located at the base of the tongue is often asymptomatic but may cause local symptoms such as dysphagia, dysphonia with stomatolalia, upper airway obstruction and haemorrhage, often with hypothyroidism. Two cases are presented, one in a 62-year-old female and the other in a 42-year-old female, both of whom complained of sensation of a foreign body and progressive dysphagia and dyspnoea caused by ectopic lingual thyroid. Treatment was performed with a partial endoscopic removal and an external cervical approach, followed by substitutive hormone treatment, respectively. Diagnostic procedures and therapeutic options are discussed and a review has been made of reports of lingual thyroid appearing in the literature.

Chondrosarcoma of the larynx: a case report.

Chondrosarcomas of the larynx are rare cancers and are more frequently located at cricoid cartilage level. They are characterised by a low tendency to metastatic diffusion (low grade). The treatment of choice is surgery, which may be endoscopic or "open partial surgery", if extension of the cancer is limited. Prognosis is generally good. In this report, a case of low malignancy chondrosarcoma of the larynx is presented, which was treated surgically with a glottic-hypoglottic laryngectomy according to Serafini-Bartual. Chondrosarcoma of the larynx shows a slow and painless growth, the first symptom is often an ingravescent dysphonia. Laryngoscopy reveals tumefaction of the larynx, covered by intact mucosa. Computerized tomography imaging with contrast and magnetic resonance imaging defines not only coarse calcifications, pathognomonic of chondromatous neo-formations but also the relationship of the neoformation with the surrounding tissues. However, histology remains the gold standard for diagnostic purposes. Treatment is essentially surgical; it must allow eradication of the cancer between specific safety margins and, it must, at the same time, be functional, if the lesion does not extend beyond half of the cricoid circle and if histological grade is low.

Altered patterns of the interferon-inducible gene IFI16 expression in head and neck squamous cell carcinoma: immunohistochemical study including correlation with retinoblastoma protein, human papillomavirus infection and proliferation index.

AIMS: To investigate whether the expression of interferon (IFN)-inducible gene IFI16 is inversely related to proliferative activity in vivo, we compared immunohistochemical reactivity of IFI16 in a series of head and neck squamous cell carcinomas (HNSCCs) with their proliferation index and the cell cycle regulator pRb. As human papillomavirus (HPV) infection is manifested by changes in the function or expression level of host genes such as IFN-inducible genes, we also investigated the presence of HPV DNA to determine whether head and neck cancers associated with HPV DNA can be distinguished from tumours that are presumably transformed by other mechanisms. METHODS: Thirty-six HNSCCs were evaluated for IFI16, pRb and Ki67 expression by immunohistochemistry. The presence of HPV was also detected by polymerase chain reaction. Nine tumours were located in the oropharynx (tonsillar area) and 27 in the larynx. RESULTS: HPV DNA was found in 14 of 25 (56%) laryngeal SCCs and in five of nine (56%) tonsillar SCC specimens examined; 17 out of the 19 HPV-DNA-positive cases showed high-grade IFI16 expression. Overall, proliferative activity was significantly related to tumour differentiation and histological grading. IFI16 protein expression was significantly inversely correlated with Ki67 (P = 0.039). Low-proliferating tumours positive for IFI16 staining showed a marked expression of pRb and a better prognosis than those whose tumours had low IFI16, pRb levels and a high proliferation index. CONCLUSIONS: To our knowledge, this is the first expression analysis of the IFN-inducible IFI16 gene in HNSCC. Low-proliferating tumours positive for IFI16 staining showed a marked expression of pRb and a better prognosis than those whose tumours had low IFI16, pRb levels and a high proliferation index.

Oncological and functional results of CO2 laser cordectomy.

Laser surgery represents the evolution of endoscopic surgery and, as far as concerns treatment of laryngeal tumours, CO2 laser cordectomy is considered a valid alternative to conventional surgery (laryngofissure cordectomy) and to exclusive radiotherapy for glottic carcinomas, classified as T1a, T1b and T2. The present report focuses on personal experience with CO2 laser cordectomy over the last 11 years, evaluating oncological and functional results. Between October 1990 and December 2001, micro-laryngoscopy has been performed with CO, laser, in 606 cases (benign and malignant lesions), of which 150 laser cordectomies, at the ORL Department, Eastern Piedmont University of Novara. An analysis is made of 63 patients (mean age 64.3 years) who underwent laser cordectomy for glottic carcinoma, observed at follow-up for at least 3 years. Vocal function has been studied on a sample of 20 patients. Of those who underwent CO2 laser cordectomy for T1a and T1s, 95.8% were disease free after a minimum of 3 years follow-up. Video-larynx-stroboscopic test highlighted the presence of a "satisfying" fibrous neocord in cases treated with Type III cordectomy. The speech compensation was of the "cord-neocordal" type (35%), false cordal (40%) and with arytenoideus hyperadduction (25%). The electro-acoustical analysis of the voice highlighted a "serious dysphonia" compatible with Type IV cases according to Yanagihara (70%) and moderate-severe dysphonia (30%). Mean values of vocal parameters were 5.8% for Jitter, 12.2% for Shimmer, 0.34 for NHR. CO2 laser cordectomy is first choice treatment for T1a glottic carcinoma, offering intra- and post-operative advantages: reduced traumatism, lack of tracheostomy, low bleeding, fast functional recovery (deglutition and speech), brief hospital stay, and low management costs. Dysphonia resulting from treatment, characterised by breathed voice, allows the patient to lead a normal life.

Centripetal approach to the facial nerve in parotid surgery: personal experience.

There is particular interest in parotid surgery on account of the close relationship between the gland and the extrapetrous facial nerve. The seventh cranial nerve is generally located by means of an anterograde or proximal surgical identification technique aimed at identifying the facial nerve at its point of exit from the stylomastoid canal. There are very few reports in the literature on retrograde or centripetal identification techniques, which may be adapted to the morphology of the neoformation limiting surgical access, in order to isolate the nerve from its peripheral rami. The present report deals with personal clinical experience, describing a technique for retrograde detection of the facial nerve. Between 1990 and 2001, 313 parotid surgery procedures were performed at the ORL Clinic of the Università del Piemonte Orientale in Novara. In 308/313 cases, corresponding to 98% of the operations, the technique chosen for the identification of the extrapetrous facial nerve was anterograde, proximal or centrifugal; in 5 cases alone, retrograde or centripetal exploration of the orbicular branch was undertaken, on account of difficulty in locating the main trunk, due to the presence of a post-inflammatory fibrosis in three patients and a stylomastoid emergency, arising from a malignant neoformation, in the other two. The decision to resort to the identification of the orbicular nerve of the eye is supported by the regular course and adequate size of this facial branch in its peripheral area, which enable it to be easily located.

[Merkel cell carcinoma]. / Tumore a cellule di Merkel.

The authors present 2 cases of Merkel cell carcinoma in the head and neck district, evaluating the characteristics and evolution. Merkel cell carcinoma is a rare, highly aggressive neuroendocrine cutaneous neoplasm which is often located in the head and neck district. This carcinoma has the same characteristics as small cell tumors and tends to significant metastatization both through the lymph nodes and through the blood. It is also prone to frequent recurrence. Today diagnosis is facilitated by electron microscopy and immunohistochemistry to search for neurofilaments and cytocheratin 20. The treatment of choice is radical surgery ensuring a tumor-free edge of at least 3 cm, associated with supplementary local radiotherapy. Recurrence is quite frequent despite the treatment strategies applied.

Post-thyroidectomy superior laryngeal nerve injury.

Voice dysfunction after thyroidectomy may be caused by damage to laryngeal nerves or lesions to strap muscles with laryngo-tracheal movement impairment. Injury to an external branch of the superior laryngeal nerve (EBSLN) is sometimes difficult to recognize clinically and its electromyographic incidence ranges from 0% to 58%. In this study we evaluated, 12-18 months postoperatively, 45 patients who had undergone thyroid surgery (6 total lobectomy, 5 subtotal thyroidectomy, and 34 total thyroidectomy), using a subjective interview, laryngeal videostroboscopy and spectrographic analysis with a multidimensional voice program. Vocal parameters included fundamental frequency, jitter, shimmer, noise-to-harmonic-ratio (NHR) and degree of sub-harmonics. Laryngeal electromyography (LEMG) of the cricothyroid (CT) muscles was performed in 21 subjects with voice problems (35 EBSLNs) using a modified method for the CT recording. In 3 patients of this group (14%) LEMG documented a unilateral EBSLN injury. Easy voice fatigue and decreased pitch range were the most common symptoms after surgery. Average values of vocal parameters pre- and postoperatively in patients without neural damage (n = 42) were: jitter 0.64% and 0.78%, shimmer 3.25% and 3.54%, and NHR 0.12% and 0.13%, respectively (P > 0.05). Acoustic analysis revealed altered patterns in some patients with no objective evidence of damage to EBSLNs, suggesting an extralaryngeal cause of vocal dysfunction, such as laryngo-tracheal fixation or lesions to strap muscles. We conclude that laryngeal videostroboscopy and spectrographic analysis are very useful to assess voice problems after thyroidectomy, including in patients without LEMG-proven neural lesions, in order to suggest early speech rehabilitation, especially in professional voice users.

Concurrent chemotherapy with carboplatin + 5-fluorouracil and radiotherapy in advanced squamous cell head and neck carcinoma: a retrospective single institution's study.

AIMS AND BACKGROUND: [corrected] The purpose of the study was to analyze the long-term follow-up of a single institution's experience with a regimen of concomitant carboplatin + 5-fluorouracil (CBDCA + 5-FU) infusion and radiotherapy. STUDY DESIGN: Fifty-eight patients with locally advanced squamous cell head and neck cancer treated with combined chemoradiotherapy between March 1990 and October 1998 were reviewed retrospectively. According to the TNM tumor staging, 6 patients had stage II, 21 stage III and 31 stage IV tumors. The chemotherapy regimen consisted of the combination of 5-FU and CBDCA, for a total of 3 cycles. Both drugs were given as 4-day continuous intravenous infusions during the first and fourth week of radiation therapy: 5-FU at 1000 mg/m2 per day and CBDCA at 75 mg/m2 per day. Radiation was given in single daily fractions of 1.8 to 2 Gy, to a total dose of 66 to 70 Gy. RESULTS: After the completion of chemotherapy and radiotherapy, 34 patients (58.6%) achieved clinical and radiological (computerized tomography and/or magnetic resonance imaging) complete remission, 15 patients (25.9%) partial remission >50%, 5 patients (8.6%) partial remission <50%, and 4 patients (6.8%) had no response. Toxicity was intensive but tolerable. After a median follow-up of 25 months, overall survival and recurrence-free survival estimated for the whole patient population was 52% at 3 years, and the median length of recurrence-free survival was 23 months. CONCLUSIONS: Our regimen combining standard single daily fraction radiation with the conventional dose of CBDCA and 5-FU was given without dose modification regardless of the severity of the adverse effects. It gave a clinical complete response at the primary site in 58.6% of patients. With a 52% projected 3-year overall survival, our series compares favorably with similar studies in the literature. Therefore, our results with concomitant CBDCA/5-FU infusion and radiotherapy are encouraging and suggest that CBDCA can be substituted for cisplatin with a good therapeutic index.

[Complications in thyroid surgery]. / Le complicanze della chirurgia tiroidea.

Today, when performed applying stringent technique, thyroid surgery can be considered a procedure with low risk of post-surgical complications. Post-surgical hypoparathyroidism is frequent (1.6-53.6% of the cases) although most of these cases are temporary, linked to functional stupor of the parathyroid glands and/or other reversible factors. Analysis of the literature has shown that preservation of 3 or more parathyroid glands is a highly positive (95%) predictive factor for normal post-operative calcemia. The incidence of recurrent definitive paralysis ranges around 0.3-2% of the nerves at risk of iatrogeneous lesions and is usually correlated with thyroid histology and with the extension and type of ablative treatment performed. The authors retrospectively consider a 10-year case study of 218 patients (222 surgical procedures, of which 17 undergoing surgery twice) analyzing endocrinological, hemorrhagic and neurological complications and paying particular attention to any vocal dysfunctions arising at a later date, even in the absence of an ascertained neurological deficit. Considering 116 total and subtotal thyroidectomies, the percentages of acute hypoparathyroidism (AH) and definitive hypoparathyroidism (DH) were, respectively, 43.9% and 6%. Four of the 7 cases of DH presented one of the factors known to increate the risk of complications: malignant thyroid histology, second surgery and/or lymph node dissection. As regards neurological sequele, the authors report an incidence of recurrent definitive paralysis of 1.8% (3 out of 35 nerves at risk examined using EMG of the cricothyroid muscle). Spectroacoustic analysis of samples from 42 subjects showed an alteration in the vocal parameters considered (jitter, shimmer, NHR and DSH) in 14-27% of the cases, even in the absence of any laryngeal nerve deficit. It may be that iatrogeneous lesions and/or scarring of prethyroid strap muscles, known to play a role in phonation mechanisms, are implicated in determining post-thyroidectomy vocal dysfunctions, seen even in patients with anatomfunctionally intact laryngeal nerves.

Rosai-Dorfman disease of the larynx.

We present a case of an 81-year-old man with a history of worsening dysphonia of six months duration. A year before a sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) was diagnosed on a submandibular lymph node biopsy. On presentation the patient showed a mass in the left subglottic area with a modest reduction in the airway space. The patient underwent an endoscopic CO2 laser excision of the mass, without post-operative complications. Histopathological examination and electron microscope images confirmed the previous diagnosis of Rosai-Dorfman disease. The clinical and pathological features of this entity are discussed.

Postoperative enteral immunonutrition in head and neck cancer patients.

AIMS: to determine if postoperative feeding of head and neck cancer patients, using an enteral diet supplemented with arginine, improves immunological and nutritional status, and clinical outcome, i.e., reduces postoperative infectious/wound complications and length of stay, when compared with an isocaloric, isonitrogenous control diet. METHODS: at operation 44 patients were randomized into two groups to receive: a) an enriched diet (n=23);b) an isocaloric, isonitrogenous control diet (n=21). Thirteen patients with a history of significant weight loss (> or = 10% over the last 6 months) were considered malnourished. Preoperatively and on postoperative days 1, 4 and 8 the following parameters were evaluated: albumin, prealbumin, transferrin, total number of lymphocytes, lymphocyte subsets (CD3, CD4, CD8 and CD4/CD8 ratio) and immunoglobulins. Postoperative complications and length of stay were recorded. RESULTS: 'visceral' serum proteins and immunological parameters decreased on postoperative day 1 in both groups. However, only the enriched group demonstrated a significant increase (P<0.05) in the total number of lymphocytes, CD4, CD4/CD8 on postoperative day 4, and total number of lymphocytes, CD3, CD4, CD4/CD8 on postoperative day 8. In the malnourished subgroup the administration of the enriched formula significantly reduced both postoperative infectious/wound complications and length of stay compared with the control group (P<0.05). CONCLUSIONS: enteral immunonutrition of head and neck cancer patients improves postoperative immunological response. Significant clinical advantages were observed in malnourished patients.

[Malformations of the first branchial cleft: a case report]. / Le malformazioni del i solco branchiale: case report.

First branchial cleft anomalies are extremely rare and account for less than 8% of all branchial anomalies. They are generally found in infancy although they arise during the embryonal period because of an incomplete closure of the first branchial cleft. In 1972 Work classified first branchial cleft anomalies into two types: Type I, ectodermal cysts, is a duplication of the external auditory duct; Type II, originate in both ectodermal and endodermal components and contain cartilage. The present case report describes a Type II branchial malformation. G.M., a 2-year-old male, presented painful tumefaction in the left parotid area with cutaneous fistulization between the sternocleidomastoid muscle and the mandibular angle. Cranial CT permitted diagnosis and made it possible to stage surgery. The difficulties encountered in recognizing and diagnosing first branchial cleft anomalies are often responsible for application of the wrong surgical approach and the resulting frequency in recurrences.

[Frontal mucocele: open surgery]. / Mucocele frontale: open surgery.

This work presents 13 cases of frontal mucoceles, 9 with endo-orbital extension. All were treated with 'open surgery': 11 using a fronto-orbital approach, 2 with a bicoronal Cairns-Unterberger approach. Four patients had recurrent mucoceles 1-20 years after the previous surgery. In one case there was an association with frontal osteoma. In 10 cases, conservative treatment was applied through repermeabilization of the infundibular region through an external, endonasal pathway and positioning of a nasal sinus drainage tube (kept in place for 4 weeks). In the remaining 3 cases, the sinus cavity was obliterated with autologous abdominal fat. This choice was made because of the presence of osteomyelitic foci, in one case mucopioceles, or by the widespread dural exposure encountered during the course of surgery. Two cases of post-operative sinus reinfection were encountered: one underwent surgical revision, the other was an orbital site recurrence arising 7 years after previous surgical obliteration of the frontal sinus. The esthetic result was unsatisfactory in 2 patients treated with a trans-facial approach. Ten patients were disease free after an average 56 months of follow-up. Although functional endoscopic surgery undoubtedly makes it possible to achieve excellent results in the treatment of most sinus mucoceles, open surgery remains a valid procedure in frontal mucoceles with orbital and/or endocranial extension and in cases where the district anatomy is unfavorable for a purely endonasal approach. The indications and limitations of open surgery are critically discussed in the light of personal experience and current literature.

CO(2) laser posterior ventriculocordectomy for the treatment of bilateral vocal cord paralysis.

We reviewed our clinical experience between 1991 and 1997 concerning use of the CO(2) laser for posterior ventriculocordectomy (PVC) for the treatment of bilateral vocal cord paralysis. Pre- and postoperative functional evaluation was assessed in a prospective setting. In all, 41 patients (33 females and 8 males) underwent an endoscopic CO(2) laser PVC. Pre- and postoperative pulmonary function tests documented a significant statistical improvement in the parameters considered. Sixteen of 21 previously tracheostomized patients were decannulated within 15 months of operation. In no case was a postoperative tracheostomy required. We found no evidence of subclinical aspiration among our cases. Evaluation of vocal parameters by spectrographic analysis was assessed in 20 patients and revealed a postoperative reduction in voice quality. Laser CO(2) PVC seems to be an effective and reliable surgical procedure that allows for rapid decannulation and gives stable results with a low incidence of revision surgery and functional failures.

[Cystic lymphangioma in the head and neck region]. / I linfangiomi cistici cervico-facciali.

Cystic lymphangioma or hygroma (CL) is a rare benign pathology of the lymphatic system characterized by multiple cystic, often non-communicating concamerations. Such lesions are most often seen in infancy and in 80% of the cases they appear within the first two years of life. They arise most commonly in the neck. CL usually tends to grow slowly and rarely regresses spontaneously. Infection and/or hemorrhage can lead to a rapid increase in size, possibly obstructing the initial portion of the upper aero-digestive tract. In the present study four patients (age range 12 months to 21 years) with head and neck CL, two with parotid primary site, were observed and treated by surgery. The lesions were studied using such imaging techniques as the color Doppler, CT and NMR. The latter permitted accurate pre-operative staging which is essential to defining and "mapping" the individual cystic concamerations. Surgery gave good results in 3 cases while in one case of multiple recurrences repeated post-operative sclerotherapy proved necessary leading to a partial reduction in the lesion. Despite the fact that numerous therapeutic options have been presented over the years, most authors today agree that the treatment of choice in cases of CL is surgery. Preparation for surgery must include accurate study with NMR, an indispensable technique for such pathologies as the T2 weighted sequences give very precise mapping. Surgical exeresis should be selective for the lesion while preserving the adjacent vascular-nervous structures.

Demonstration of multiple HPV types in laryngeal premalignant lesions using polymerase chain reaction and immunohistochemistry.

Recent evidence has shown that human papillomavirus (HPV) is involved in both the development of carcinoma and in premalignant mucosal lesions of the oral cavity. This study examined the relationship of HPV infection to some pathological features in precancerous lesions of the larynx, not examined extensively so far. Fifty formalin-fixed paraffin-embedded tissue sections containing human laryngeal precancerous lesions were screened for the presence of HPV infection by polymerase chain reaction, and for capsid protein expression by immunohistochemistry with polyclonal antibody directed against the L1 protein. The presence of HPV DNA was detected in 28 of 50 specimens (56%), including 9/12 cases with mild dysplasia (75%), 3/6 cases with moderate dysplasia (50%), and 7/11 cases with severe dysplasia (64%). Multiple HPV infections, containing two or three types, were detected in 17 of the 28 HPV-positive lesions (60%). Of 21 cases with keratosis and no dysplasia, 11 were positive for HPV DNA (52%) and 4 showed L1 staining (36%). By contrast, L1 positivity was revealed only in two lesions with moderate dysplasia, confirming that fully productive HPV infection is strictly dependent on epithelial differentiation and surface keratinization. The probability that HPV is a cofactor in the malignant progression of these lesions is suggested by the fact that 3/4 patients who developed cancer within 50 months were positive for HPV DNA.

[Microsurgical treatment of ethmoid-sphenoidal fluid fistula]. / Trattamento microchirurgico delle fistole liquorali etmoido-sfenoidali.

Traumatic basal skull fracture and iatrogenic injury during surgery are the main causes of cerebrospinal fluid (CSF) fistulas. The roof of the ethmoid and the cribriform plate are the most frequent sites of CSF rhinorrhea. The technique for repairing CSF leaks has evolved from intracranial repair to extracranial approaches. From March 1995 to June 1996 five patients with CSF rhinorrhea underwent microsurgical transnasal repair. In four cases of ethmoid defects, a pedicled vascularized mucoperiostal flap was obtained from the ipsilateral septum and placed over the defect. The fifth CSF leak came from the sphenoid and was repaired by packing the sinus cavity with abdominal fat. In all cases the CSF pressure was reduced with a lumbar drain for 5-10 days. The nasal packing was removed on the 5th day. All five patients have been followed up regularly for at least 6 months. To date there has been no evidence of recurrence. The surgical microscopic approach has some advantages: it permits good control of the surgical field and bleeding. In addition, stereoscopic vision provides the surgeon with a meticulous apposition between the flap and the CSF leak. The surgical technique is discussed in detail.

[Doppler-color ultrasonography in the diagnosis of parotid tumors]. / Eco-color-doppler nella diagnostica delle masse parotidee.

Today ultrasound, often integrated with CT and NMR, is used in the differential diagnosis of parotid masses. Color-Doppler Sonography is a recently introduced method which makes it possible to evaluate intra- and perilesional vascularization and to perform a hemodynamic study of the area being explored. Using an Acuson 12P ultrasound unit 21 patients with surgically treated parotid neoformations were examined. All had previously undergone traditional ultrasound and CT. An abundant vascularization, both intralesional and peripheral, was found in 4 malignant lesions, in one intraglandular granulomatose lymph adenopathy, in one pleomorphic adenoma of the deep lobe and in one case of Sjögren's syndrome. In the remaining cases (7 pleomorphic adenomas and 7 cystoadenolymphomas) vascularization was either totally absent or only slightly visible in the periphery. These preliminary results would appear to indicate that the presence of hypervascularization testifies to a malignant lesion or to an inflammatory disorder. The Color-Doppler Sonography can provide a useful adjunct to conventional ultrasound, increasing diagnostic accuracy in cervical-parotid masses.

[CO2 laser treatment in laryngeal papillomatosis]. / Il trattamento laser CO2 della papillomatosi laringea.

Laryngeal papillomatosis is a rare, unpredictable pathology which often recurs. Although several forms of surgery have been suggested for this pathology, CO2 laser surgery is the treatment of choice. This paper presents 30 cases of laryngeal papillomatosis, 12 of which arose in infancy, all treated by dissection and/or CO2 laser vaporization. The treatments were performed in one or more stages depending on the site and appearance of the lesions. Special care must be taken to preserve the anatomical integrity when a papillomatosis must be removed from the glottic area. The average number of surgical procedures per patient proved greater in multifocal vs. unifocal forms (4.7 vs. 1.6) and in children vs. adults (4.9 vs. 3.7). In four patients the pathology followed a neoplastic evolution. Today 57% of the subjects treated (17) are in clinical remission after an average 17 month follow-up. CO2 laser endoscopic microsurgery is presently the most suitable method for treating laryngeal papillomatosis although the biological features of this diseases often make treatment difficult.

[Indications and methods for rhino-pharyngo-laryngeal fibroscopy in children]. / Indicazioni e metodiche della fibroscopia rinofaringolaringea in età pediatrica.

Flexible rhinopharyngolaryngoscopy (RFL) has now definitively replaced rigid endoscopy in the diagnosis of VADS in children owing to its ease of use and handling, also in the case of patients who are not wholly cooperative. RFL also enables the morphology and laryngeal function to be evaluated in children without risks for the patient provided the operator complies with a few simple precautions during diagnosis. During elective diagnosis, the patient must be in a fasting state and must not present uncompensated coagulopathies. The main indications for RFL are dyspnea, dysphonia and stridor, given that the VADS regions can be easily displayed. The current limits of this method are the impossibility of allowing therapeutic interventions and the impossibility of passing beyond the glottic level without local anesthesia.