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PubMed2002

[Prevalence of gastro-oesophageal reflux disease in general practice].

BACKGROUND AND OBJECTIVE: While there is an ever rising prevalence of gastro-oesophageal reflux disease among people in the western world, the actual number are usually underestimated, because many afflicted persons do not seek medical care. This study was undertaken to determine the frequency of unrecognized reflux disease among an unselected patient cohort in general practice. In addition, answers by these patients to a questionnaire were evaluated. PATIENTS AND METHODS: 162 consecutive patients of a general practice without known gastro-oesophageal reflux took part. After the questionnaire had been filled in a history was obtained with semi-quantitative grading of dyspeptic symptoms, and all underwent a physical examination. A gastroscopy was offered to all patients. Gastro-oesophageal reflux was diagnosed when endoscopy revealed typical oesophageal lesions and/or there were at least moderately severe reflux symptoms that had reduced the patient's quality of life. RESULTS: 82 patients (51%) had reflux disease. 121 patients underwent endoscopy. Structural changes (reflux oesophagitis, Barrett metaplasia) were seen in 28 of the 82 patients with reflux disease (34%), 17% of the entire cohort. Axial hiatus hernia, positive family history, advancing age, over-weight, female gender and treatment with NSAIDs or aspirin were significant risk factors in the development of reflux disease. Patients with reflux disease significantly more frequently suffered from hoarseness and/or cough. Positive or negative predictability of the questionnaire regarding the diagnosis of reflux disease was 94% each way. CONCLUSION: The prevalence of unrecognized gastro-oesophageal reflux disease in the population is extraordinarily high. One quarter to one third of those with reflux disease have cough or hoarseness. The disease can apparently be reliably diagnosed by a standardized questionnaire.

Adult↗
PubMed2005

[Voice function and quality of life--patients with laryngeal carcinoma following minimal-invasive laser surgery and function voice rehabilitation].

BACKGROUND: Quality of life is a relevant criterion for therapeutical outcome in laryngeal carcinoma patients. The aim of this study was to assess the self-related complaints in quality of life and functional outcome of voice among persons who had undergone laryngeal cancer surgery. METHODS: The examination took place 67 months (SD 34.8) after the last surgery, on average and finishing of 60 therapy sessions (median). First a measurement with the Goettinger Hoarseness Diagram (GHD) was carried out. Next the subjects answered self-reported standardized questionnaires for life quality in oncological patients on the same day: EORTC-QLQ-C30 and 3 scales of the German Fragebogen zur Lebenszufriedenheit (health-related fulfillment, fulfillment with work/occupation, fulfillment with social environment). For disease-related symptoms of different head and neck domains the EORTC-HandN35 was administered. SUBJECTS: Forty-four patients (37 males, 7 females) who were treated primarily with minimal invasive laser surgery followed by functional voice rehabilitation (Goettinger Konzept). Mean age: 60.1 (SD 9.7) years. RESULTS: The acoustic voice quality according to the GHD showed a significant correlation with self-reported "Somatic Functioning" (- 0.32, p = 0.04) and "Social Functioning" (- 0.38, p = 0.01) in the EORTC-QLQ-C30 as well as with the symptom scales "Speech" (0.45, p < 0.0024) resp. "Social Contact" (0.45, p = 0.0021) in the EORTC-HandN35. Also hoarseness and health-related fulfillment (- 0.36, p = 0.02) as well as fulfillment with work/occupation (- 0.33, p = 0.03) correlated significantly. On the other hand, there was no significant association between the GHD and the assessment of global quality of life. CONCLUSION: Postoperative phonatory reductions in patients with laser surgically treated laryngeal carcinoma have only a slight influence on overall quality of life. The same is true for the GHD. Assessment of self-reported quality of life in recommendation of oncologic treatment may not be able to replace the objective findings, but may be useful to detect other problems, e.g. psychosocial.

Aged↗
PubMed1993

Tuberculous laryngitis in a Nigerian child.

A 12.5-year-old Nigerian child presented with progressively worsening hoarseness of 9 months duration, without overt features of chronic ill health. Superficial discrete cervical adenitis, radiological evidence of miliary tuberculosis and hilar adenopathy were identified on admission. The laryngoscopic findings comprised fully mobile but 'beefy' red, oedematous vocal cords and interarytenoid region. The diagnosis of tuberculous laryngitis was made on the basis of the laryngoscopic, radiological and clinical improvement that followed antituberculous therapy. The possible pathogeneses of tuberculous laryngitis are discussed. We emphasize the importance of considering tuberculous laryngitis in a child with persistent hoarseness.

Child↗
PubMed2006

An asymmetric smooth contour two-mass model for recurrent laryngeal nerve paralysis.

Irregular vocal fold vibrations are assumed to be a major cause of hoarseness. A common clinical condition presenting with hoarseness is a unilateral recurrent laryngeal nerve paralysis (RLNP). In order to explain high-speed video recordings of clinical RLNP, RLNP-type vocal fold vibrations are simulated by extending the well known two-mass model (2MM) to an asymmetric smooth-contour two-mass model (SC2MM). Polynomial interpolations form a smooth surface over the lumped elements of the 2MM. Laryngeal asymmetry is accounted for by introduction of an asymmetry coefficient and an anterior commissure angle which models a variable glottal closure insufficiency. Compared to the 2MM, the SC2MM yields a smaller glottal volume flow and is more stable in critical parameter constellations of RLNP-like conditions. It is able to model the vocal fold dynamics during a glottal closure insufficiency.

Biomechanical Phenomena↗
PubMed2005

Arytenoid cartilage dislocation caused by a double-lumen endobronchial tube.

Following surgery requiring the use of a double-lumen endobronchial tube, a patient immediately complained of persistent severe hoarseness. On the third day after the operation, fibreoptic laryngoscopy revealed posterolateral dislocation of the left arytenoid cartilage. By the sixth day of the operation, a slight improvement was observed in the hoarseness without treatment and a spontaneous recovery of arytenoid cartilage dislocation was expected. The patient did not consent to surgical treatment, and therefore a conservative therapy was selected. Ten weeks after the operation, it was found that the dislocated left arytenoid cartilage had spontaneously repositioned and the patient regained his normal voice. The causes and treatment options are discussed.

Arytenoid Cartilage↗
PubMed2005

Autosomal dominant hereditary sensory neuropathy with chronic cough and gastro-oesophageal reflux: clinical features in two families linked to chromosome 3p22-p24.

Autosomal dominant hereditary sensory neuropathy (HSN I) is a clinically and genetically heterogeneous group of disorders, and in some families it is due to mutations in the serine palmitoyltransferase (SPTLC1) gene. We have characterized two families with HSN I associated with cough and gastro-oesophageal reflux (GOR). From a large Australian family, 27 individuals and from a smaller family, 11 individuals provided clinical information and blood for genetic analysis. Affected individuals had an adult onset of paroxysmal cough, GOR and distal sensory loss. Cough could be triggered by noxious odours or by pressure in the external auditory canal (Arnold's ear-cough reflex). Other features included throat clearing, hoarse voice, cough syncope and sensorineural hearing loss. Neurophysiological and pathological studies demonstrated a sensory axonal neuropathy. Gastric emptying studies were normal, and autonomic function and sweat tests were either normal or showed distal hypohidrosis. Cough was likely to be due to a combination of denervation hypersensitivity of the upper airways and oesophagus, and prominent GOR. Most affected individuals were shown on 24 h ambulatory oesophageal pH monitoring to have multiple episodes of GOR, closely temporally associated with coughing. Hoarse voice was probably attributable to acid-induced laryngeal damage, and there was no evidence of vocal cord palsy. No other cause for cough was found on most respiratory or otorhinological studies. Linkage to chromosome 3p22-p24 has been found in both families, with no evidence of linkage to loci for known HSN I, autosomal dominant hereditary motor and sensory neuropathy, hereditary GOR or triple A syndrome. These families represent a genetically novel variant of HSN I, with a distinctive cough owing to involvement of the upper aerodigestive tract.

Adult↗
PubMed2001

Pharyngolaryngeal morbidity with the laryngeal mask airway in spontaneously breathing patients: does size matter?

BACKGROUND: Currently, the manufacturer of the laryngeal mask airway (LMA; Laryngeal Mask Company, Ltd., Northfield End, Henley on Thames, Oxon, United Kingdom) recommends using as large a mask size as possible. The aim of this study was to compare the incidence of pharyngolaryngeal morbidity after the use of a large (size 5 in males and size 4 in females) or small (size 4 in males and size 3 in females) LMA in spontaneously breathing patients. METHODS: A total of 258 male and female patients were randomly assigned to insertion of a large or small LMA while breathing spontaneously during general anesthesia. After insertion of the LMA, a "just-seal" cuff pressure was obtained, and intracuff pressure was measured at 10-min intervals until just before removal of the LMA. The 2- and 24-h incidence of postoperative sore throat, pain, hoarseness, dysphagia, and nausea and vomiting was assessed. Complications after LMA removal, including body movement, coughing, retching, regurgitation, vomiting, biting on the LMA, bronchospasm, laryngospasm, or the presence of blood on the LMA, were recorded. RESULTS: The use of a large LMA was associated with a higher incidence of sore throat in both sexes (20% vs. 7% in men, 21% vs. 5% in women; P < 0.05) and a higher incidence of hoarseness in male patients at 2 h postoperatively (21% vs. 9%, P < 0.05). There was a higher incidence of sore throat in male patients at 24 h postoperatively with the use of a large LMA (26% vs. 12%, P < 0.05). There was no difference in the incidence of complications of LMA removal orother pharyngolaryngeal morbidity, such as difficulty swallowing, drinking, and eating, or nausea and vomiting, between male or female groups at any time period with the use of a large LMA. CONCLUSIONS: Selection of a small laryngeal mask airway (size 4) in spontaneously breathing male patients may be more appropriate to limit the occurrence of sore throat on the first postoperative day. All patients had a fourfold increased risk of developing sore throat when a large LMA was used.

Adult↗
PubMed1998

Vocal mechanics as the basis for phonosurgery.

OBJECTIVE: A number of modifications in laryngoplastic phonosurgery have recently been proposed. This report is intended to clarify the concept on which the surgery should be based, vocal mechanics, for further rational development of the surgery. STUDY DESIGN: The results of various previous surgeries were compared. In an attempt to elucidate what makes the difference in the results, simulation of voice production was conducted with the use of excised larynges. METHODS: Excised larynges were mounted on a tube so as to be blown from below. Experimental variables in the model included the glottal area initially set, stiffness of the vocal folds, and subglottal pressure. The conditions under which the voice became hoarse were examined. RESULTS: The voice became hoarse under the following major conditions: 1) the initial glottal area exceeded a certain value, 2) stiffness was too high, and 3) the glottis was too tightly closed. Clinical representation for each condition was made, particularly for excessively tight glottal closure such as in spasmodic dysphonia. A new type of surgical treatment for spasmodic dysphonia, lateralization thyroplasty, was briefly reported, which restored the voice to normal without recurrence for 1 year at the time of this writing. CONCLUSIONS: A potential new type of laryngoplastic phonosurgery should be conformed to the mechanics of voice production. In treating dysphonia, it is often necessary to switch from etiologic or radical treatment, if infertile, to symptomatic treatment instead, at the level of mechanics.

Biomechanical Phenomena↗
PubMed1997

Laryngeal manifestations of gastroesophageal reflux before and after treatment with omeprazole.

BACKGROUND: Laryngeal manifestations of gastroesophageal reflux disease are thought to be prevalent in our society. In general, diagnosis has been primarily based on symptoms. Historically, additional testing has included laryngoscopy, barium swallow, manometry, and single and double probe pH monitoring. METHODS: We assessed 96 patients who had symptoms suggestive of reflux laryngitis. We administered surveys grading their symptoms. All patients had standardized videolaryngostroboscopic evaluation and computerized acoustic analysis. Patients then received a uniform regimen of dietary restrictions and omeprazole (a proton pump inhibitor) for 12 weeks, after which they were retested. RESULTS: Using the new laryngoscopic grading system, we found that this regimen produced statistically significant improvement in all symptoms except granulomas. In patients with the pretherapy complaint of hoarseness, acoustic measurements of jitter, shimmer, habitual frequency, and frequency range all showed significant improvement. CONCLUSIONS: We conclude that in patients with symptomatic reflux laryngitis, standardized videolaryngoscopy and, if the patient is hoarse, acoustic analysis are useful techniques to aid diagnosis and monitor therapy. Antireflux therapy with omeprazole is effective, and improvement can be objectively shown with the techniques described.

Adult↗
PubMed2006

Prevalence of atypical symptoms and their association with typical symptoms of gastroesophageal reflux in Spain.

BACKGROUND: The association between typical and atypical symptoms of gastroesophageal reflux (GER) has received little attention in population-based studies. This study therefore sought to examine the prevalence of atypical symptoms, and their association with typical GER symptoms in Spain. METHODS: A telephone survey using a validated questionnaire was conducted in 2002 on 2500 subjects aged 40-79 years, randomly selected from the general population of Spain. The questionnaire included items on typical GER symptoms (heartburn and acid regurgitation) and several atypical symptoms (chest pain, dysphagia, belching, dyspepsia, globus, hoarseness, hiccups, chronic cough and asthma). The association between typical GER symptoms and each atypical symptom was summarized using odds ratios obtained from logistic regression. RESULTS: The response rate was 71.2%. A total of 60.8% (95% confidence interval 59.0-62.8%) of subjects reported suffering from at least one atypical symptom during the year preceding the interview. The prevalence rates varied from 26.7% for hoarseness to 6.6% for asthma. The prevalence of atypical symptoms was higher among the 791 subjects with typical GER symptoms than among the 1709 subjects reporting no typical GER symptoms (79.6 versus 52.2%). It was also higher among those reporting frequent typical GER symptoms compared with those reporting occasional symptoms (87.8 versus 58%). After adjustment for age, sex, coffee, alcohol and tobacco consumption, and psychosomatic symptoms, an association (P<0.05) was observed between typical symptoms and the respective atypical symptoms, with odds ratios ranging from 1.4 for asthma to 4.6 for belching. After additional adjustment for the remaining atypical symptoms, chest pain, dysphagia, dyspepsia, belching and globus were each independently associated with typical reflux symptoms. CONCLUSION: The prevalence of atypical GER symptoms is extremely high. There is an association between typical and atypical GER symptoms, particularly chest pain, dysphagia, dyspepsia, belching and globus.

Adult↗
PubMed2006

Early laryngeal inhalation injury and its correlation with late sequelae.

OBJECTIVE: Inhalation injury can permanently alter normal laryngeal function. The aim of this study was to examine the early changes in voice, swallowing, and breathing in laryngeal inhalation injuries. STUDY DESIGN: This was a prospective analysis of nine patients with inhalation injuries at a tertiary care institution. METHODS: Laryngeal function of patients admitted for inhalation injury requiring intubation was documented using videostroboscopy and swallowing evaluation by the speech pathology service. Bronchoscopy was used to classify the degree of inhalation injury. Association among total body surface area, facial burns, severity of laryngotracheal injuries, and loss of function was attempted. RESULTS: All three patients with severe tracheal inhalation injury presented persistent hoarseness at 1-year follow up with abnormal videostroboscopy findings. No association was found between inhalation injury and total body surface area burned. None of the patients in this series presented permanent swallowing dysfunction. CONCLUSION: The otolaryngologist plays an important role in the initial and long-term management of inhalation injuries. Inhalation injuries should be managed in a multidisciplinary fashion. There may be a correlation between the degree of tracheal injury and laryngeal injury and hoarseness.

Adult↗
PubMed2004

A comparison of the intubating laryngeal mask airway and the Bonfils intubation fibrescope in patients with predicted difficult airways.

Tracheal intubation with the intubating laryngeal mask airway or the Bonfils intubation fibrescope was performed in 80 patients with predicted difficult airways. Mallampati score, thyromental distance, mouth opening and mobility of the atlanto-occipital joint were used to predict difficult airways. The overall success rate, time to the first adequate lung ventilation and time taken for the successful placement of the tracheal tube were recorded, as well as a subjective assessment of the handling of the device and the incidence of postoperative sore throat and hoarseness. The median [range] time to the first adequate ventilation was significantly shorter with the intubating laryngeal mask airway than with the Bonfils intubation fibrescope (28 [6-85] s vs. 40 [23-77] s, p < 0.005). Tracheal intubation was significantly slower with the intubating laryngeal mask airway than with the Bonfils intubation fibrescope (76 [45-155] s vs. 40 [23-77] s, p < 0.0001. Patients in the Bonfils group suffered less sore throat and hoarseness than those in the other group.

Adolescent↗
PubMed2004

Clinical and molecular characterization of lipoid proteinosis in Namaqualand, South Africa.

BACKGROUND: Lipoid proteinosis (LiP) is a rare autosomal recessive disorder characterized by a hoarse voice, warty skin infiltration and scarring. Mutations within the extracellular matrix protein 1 (ECM1) gene cause LiP. Since the early 1970s it has been recognized that South Africa has one of the largest groups of LiP patients worldwide, suggesting a probable founder effect. As LiP patients present with considerable clinical variability, this group of patients offers a unique opportunity for genotype-phenotype correlation. OBJECTIVES: To assess the clinical features and the molecular basis of LiP in patients from the Namaqualand area of the Northern Cape province of South Africa and to examine molecular evidence for a founder effect. SUBJECTS AND METHODS: The LiP patient cohort consisted of 29 Coloured patients from Namaqualand and a further seven Caucasoid patients from other areas of South Africa. The control group included 100 healthy geographically and ethnically matched individuals from Namaqualand. Samples were collected after informed consent and with ethics committee approval from the University of the Witwatersrand. LiP patients were examined clinically and a structured recording sheet was completed. A brief neurological evaluation was also performed. The LiP founder effect was investigated at the molecular level by ECM1 mutation detection and haplotype analysis. RESULTS: The most consistent clinical signs for a diagnosis of LiP in this group were a hoarse voice and thickened sublingual frenulum leading to restricted tongue movement. Homozygosity for a nonsense mutation in exon 7 of the ECM1 gene, Q276X, was identified in all patients (Coloured and Caucasoid). Despite this genetic homogeneity, considerable clinical variability in skin presentation and psychiatric involvement was observed. Haplotype analysis using markers from a 9.98-Mb region around the ECM1 locus confirmed the founder effect with a founder core haplotype, 19-Q276X-12 (ND1-ECM1-D1S2343), in all but four LiP-associated alleles (n = 58). A LiP carrier rate of 1 in 9 was observed among the 100 Namaqualand controls, predicting a LiP incidence of 1 in 324 in this community. CONCLUSIONS: Although several consistent clinical features in LiP patients homozygous for the Q276X mutation in the ECM1 gene were observed, there remains considerable clinical variability. This suggests the action of genetic and environmental modifiers of disease severity. Strong molecular evidence supports a single founder effect for the high prevalence of LiP in South Africans, both Coloured and Caucasoid.

Adolescent↗
PubMed1992

The quantitative analysis of dysphonia.

A clinical method of measuring 'hoarseness' is presented. Its value is assessed in 3 different types of vocal cord lesion and compared against normal values. There are shown to be significant differences between the normal and the abnormal voice and also differences between each type of vocal cord lesion. We feel that this quantification of hoarseness is useful in the treatment of patients as well as in monitoring their progress under therapy.

Adult↗
PubMed2005

Pharyngeal and laryngeal symptoms and signs related to extraesophageal reflux in patients with heartburn in gastroenterology practice: a prospective study.

OBJECTIVES: To describe pharyngeal and laryngeal symptoms and findings in correlation to extraesophageal reflux (EER) in patients with heartburn. DESIGN: A prospective study. SETTING: Patients referred to Department of Gastroenterology, Karolinska University Hospital Huddinge. PARTICIPANTS: Forty-three patients with chronic heartburn as the primary symptom, subdivided on the basis of oesophageal manometry to have gastro-oesophageal reflux disease (GORD) (n = 25) or not (n = 18). MAIN OUTCOME MEASURES: Laryngeal video recordings of 43 patients were examined off-line. The occurrence of symptoms and laryngeal pathology were correlated to the results of 24-h double-probe pH monitoring. RESULTS: Pharyngeal or laryngeal symptoms occurred often or quite often in 72% (18 of 25) of the GORD patients and 61% (11 of 18) of the patients without GORD. EER occurred in 73% (16 of 22) of the GORD patients with laryngeal symptoms and in 38% (6 of 16) of those without GORD but with laryngeal symptoms (P = 0.047). In the multivariate analysis the odds for hoarseness was 17 times higher if the patient had heartburn more than five times a day, compared with patients with heartburn less than once a day (OR 17.8, CI 1.7-405.9; P = 0.01). Cohen's kappa for intrarater reliability was 0.851 (P = 0.001). Laryngeal pathology was found in 56% of the GORD patients and 44% patients without GORD. There was no significant difference in the occurrence of any specific symptom or finding between the patients with and without GORD, nor with and without EER. CONCLUSIONS: Although GORD together with laryngeal symptoms seem to be predictive of EER, there are no specific pharyngeal and laryngeal symptoms or findings that would help distinguishing patients with EER from those without. However, the more frequent the heartburn to the more frequent is hoarseness.

Adult↗
PubMed2005

Unilateral recurrent laryngeal nerve neuropraxia following placement of a ProSeal laryngeal mask airway in a patient with CREST syndrome.

We report a severe unilateral recurrent laryngeal nerve neuropraxia following use of the ProSeal laryngeal mask airway (PLMA) in a 71-year-old female patient with CREST syndrome. She required amputation of the 5th phalanx of foot because of gangrene due to Raynaud's syndrome. Anesthesia was induced with propofol, and a size 3 PLMA was inserted. Anesthesia was maintained with sevoflurane and nitrous oxide for 2 h and the operation was performed uneventfully. On removal of PLMA, the cuff volume was measured to 40 ml. The patient did not complain of respiratory discomfort shortly after PLMA removal. However, the next day she developed dysphagia and hoarseness. Laryngoscopic examination revealed unilateral vocal cord paralysis. Cricothyrotomy was required because of suspected silent aspiration pneumonia. The pharyngolaryngeal complications improved with a mobile vocal cord but slight hoarseness after 2 months. We considered the patient's CREST syndrome with a potential of tissue ischemia, and the high intracuff pressure of the PLMA due to nitrous oxide influx, to be the cause of severe recurrent laryngeal nerve neuropraxia in this case.

Aged↗
PubMed2004

A Christmas tree in the larynx.

A 2 year-old boy presented with acute upper airway obstruction following a 15-month history of noisy breathing and hoarseness. An urgent laryngotracheal bronchoscopy was performed following inhalational induction of anesthesia. Using a fiberoptic bronchoscope, visualization of the larynx through a laryngeal mask airway revealed a flat plastic Christmas tree embedded within granulomatous cords causing almost complete obstruction and requiring tracheostomy prior to extraction. Twelve days later, the tracheostomy was successfully decannulated with the child's voice beginning to normalize. The family remembered the decoration from Christmas celebrations 2 years prior and recalled a coughing episode that predated the onset of hoarseness.

Airway Obstruction↗
PubMedDate not supplied

Vagus nerve stimulation for treatment of partial seizures: 2. Safety, side effects, and tolerability. First International Vagus Nerve Stimulation Study Group.

Vagus nerve stimulation (VNS) significantly reduces the frequency of partial seizures in refractory epilepsy patients. We examined the serious adverse events, side effects, and tolerability as they relate to the surgical implant procedure and the stimulating device. We also reviewed potential drug interactions, device output complications, and impact of the therapy on overall health status. We analyzed the first 67 patients to exist the acute phase of the EO3 VNS trial comparing high (therapeutic) VNS to low (less or noneffective) VNS. Data were collected from case report forms used at each of the four visits during the 12-week baseline and at each of the four visits during the 14-week randomized phase of the trial. No significant complications were reported as a result of the implant procedure. Serious adverse events included 1 patient who experienced direct current to the vagus nerve owing to generator malfunction resulting in left vocal cord paralysis and withdrawal of the patient from the study. No clinically significant effects on vital signs, cardiac function, or gastric function were detected. Side effects associated with VNS in the high group were hoarseness (35.5%), coughing (13.9%), and throat pain (12.9%). In the low group, only hoarseness (13.9%) and throat pain (13.9%) were associated with VNS. These effects generally wrre not considered clinically significant and occurred primarily during the stimulation pulses. No patients discontinued VNS therapy during the acute phase because of side effects associated with normal stimulation. Except for the one instance of a short circuit in the system resulting in a direct current, stimulating system complications were minor, limited to programming, unscheduled stimulation, and high lead impedance. Patients, investigators, and patient companions rated patients receiving high stimulation as more "improved" than those receiving low stimulation in regards to overall health status. Antiepileptic drug (AED) plasma concentrations were not affected by VNS. The implant procedure, stimulating system, and therapy proved safe and tolerable during the study. The high percentage (67 of 68) of patients completing the study reflects patient acceptance and tolerability of this mode of therapy.

Adolescent↗