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OBJECTIVES/HYPOTHESIS: To determine the presence of sex differences in difficult laryngeal exposure and the Laryngoscore, validate the Laryngoscore, mini-Laryngoscore, and Clarysse's model for predicting difficult laryngeal exposure, and modify the Laryngoscore for improved prediction accuracy. STUDY DESIGN: Retrospective study. METHODS: This study included 153 patients who underwent laryngeal microsurgery at a tertiary laryngology center and university hospital. Patients were evaluated using the 11 items of the Laryngoscore, mini-Laryngoscore, and Clarysse's model to predict difficult laryngeal exposure. Difficult laryngeal exposure was defined as the inability to view the anterior commissure through a rigid laryngoscope under counterpressure to the anterior neck. Descriptive statistics and receiver-operating characteristic curve analysis were used to assess the diagnostic performance of the predictive models and variables, including sex. RESULTS: The prevalence of difficult laryngeal exposure was significantly higher in men than in women, despite higher Laryngoscore values in females. The Laryngoscore, mini-Laryngoscore, and Clarysse's model demonstrated good diagnostic performance with C-indexes of 0.751, 0.727, and 0.783, respectively. Based on these findings, we proposed a modified Laryngoscore, including treatment history, interincisors gap, upper jaw dental status, thyro-mental distance, degree of neck flexion-extension, and sex, achieving a C-index of 0.835. CONCLUSIONS: Inclusion of sex in the Laryngoscore and related predictive models enhances the accuracy of predicting difficult laryngeal exposure. These findings support the inclusion of sex as a factor in future modifications of these models to improve their predictive performance.
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OBJECTIVES: Considerable research has been focused on independent predictors of difficult laryngeal exposure (DLE) during suspension laryngoscopy. However, previous studies have yielded inconsistent results and conclusions. Consequently, we performed a meta-analysis of the existing literature with the aim of identifying significant parameters for a standardized preoperative DLE prediction system. METHODS: We systematically retrieved articles from the PubMed, Embase, Web of Science, China National Knowledge Infrastructure, and Wanfang databases up to October 2022. Data from eligible studies were extracted and analyzed using the R programming language. The effect measures included odds ratios (ORs) with 95% confidence intervals (CIs) for dichotomous variables and mean differences (MDs) with 95% CIs for continuous variables. RESULTS: The search yielded 1,574 studies, of which 18 (involving a total of 2,263 patients) were included. Pooled analysis demonstrated that patients with DLE during microsurgery tended to be male (OR, 1.73; 95% CI, 1.16-2.57); were older (MD, 5.47 years, 95% CI, 2.44-8.51 years); had a higher body mass index (BMI; MD, 1.19 kg/m2; 95% CI, 0.33-2.05 kg/m2); had a greater neck circumference (MD, 2.50 cm; 95% CI, 1.56-3.44 cm); exhibited limited mouth opening (MD, -0.52 cm; 95% CI, -0.88 to -0.15 cm); had limited neck flexibility (MD, -10.05 cm; 95% CI, -14.10 to -6.00 cm); displayed various other anatomical characteristics; and had a high modified Mallampati index (MMI) or test score (OR, 3.37; 95% CI, 2.07-5.48). CONCLUSION: We conducted a comprehensive and systematic analysis of the factors relevant to DLE. Ultimately, we identified sex, age, BMI, neck circumference, MMI, inter-incisor gap, hyomental distance, thyromental distance, sternomental distance, and flexion-extension angle as factors highly correlated with DLE.
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Introduction: The proper visualisation of the larynx is required for the diagnostic assessment and therapeutic intervention. The most significant challenges for surgeon is to visualise the anterior commissure of the glottis region. The aim of this study is to record the preoperative laryngoscore in patients posted for endolaryngeal surgery and to assess preoperative predictors for intraoperative difficult laryngeal exposure by correlating with preoperative laryngoscore. Design: Prospective, Cross-sectional, Observational study. Setting: Department of Otorhinolaryngology in a tertiary care teaching facility. Subjects: 150 patients were included with an endolaryngeal disease who were planned for surgery with age > 18yrs. Methodology: In 150 subjects preoperative laryngoscore was calculated, which comprised 11 parameters including thyromental distance, mandibular prognathism, macroglossia, micrognathia, trismus, inter incisor gap, degree of neck flexion-extension, history of prior open-neck surgery or radiotherapy, upper jaw dental status, modified Mallampati score and body mass index in order to produce a total score out of a possible maximum score of 17. According to the anterior commissure visualisation all patients were categorised into five classes, ranging from class 0 to class IV during surgery. The laryngoscore parameters were assessed and compared statistically with five classes of intraoperative anterior commissure visualisation. Result: Out of 150 patients 70 (46.6%) were having 3-4 laryngoscore, followed by 45 (30%) patients with 5-6 laryngoscore. Total 123 (82%) patient had class 0,1 and 2 intraoperative anterior commissure visualisation while 27 (18%) had class 3 and 4 visualisation. If laryngoscore was either less or equal to 5, 90% of the patients had excellent laryngeal exposure whereas only 10% of the patients had challenging laryngeal exposure. At univariate analysis, thyromental distance, degree of neck flexion/extension, and modified Mallampati classification were found statistically significant for difficulty of anterior commissure visualisation independently. Conclusion: A sound, easy and valid preoperative laryngoscore may be significantly helpful in identifying intraoperative difficult laryngeal exposure. This may prevent inadequacy of surgery, abandon of surgery, intra operative complication, and medico-legal cases for laryngologist.
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PURPOSE: Successful microlaryngeal surgery relies on an adequate laryngeal exposure. Recognizing the likelihood of challenging exposure prior to microlaryngeal surgery may assist in selecting the appropriate surgical approach and even prompt consideration of alternative treatment options. We aim to apply the mini-Laryngoscore, a preoperative assessment tool, to our study population and incorporate novel variables to optimize the prediction model. METHODS: This single-center prospective cohort study included 80 consecutive patients undergoing elective microlaryngeal surgery, from January 1, to June 30, 2023. Each patient underwent a presurgical evaluation of 15 parameters and an intraoperative scoring of the anterior commissure visualization. These parameters were assessed for their association with difficult laryngeal exposure, using multiple logistic regression analysis. We created a novel prediction model for DLE and compared it with the existing model, the mini-Laryngoscore. RESULTS: Out of 80 patients, 24 (30%) patients had difficult laryngeal exposure, including 3 cases (3.8%) in which visualization of the anterior commissure was not possible. A large neck diameter (OR, 1.4; CI 1.1-1.9) and the presence of upper teeth (OR, 8.9; CI 1.3-62.8) were independent risk factors for a difficult laryngeal exposure, while a larger interincisors gap was the only independent protector factor (OR, 0.3; CI 0.1-0.8). The logistic regression model combining these three independent risk factors displayed a high discriminative value AUC = 0.89 (CI 0.81-0.97). The predictive performance of the mini-Laryngoscore was 0.73 (CI 0.62-0.85). CONCLUSION: Combining two parameters from the mini-Laryngoscore (upper jaw dental state and interincisors gap distance) with neck circumference measurement can accurately predict the risk of difficult laryngeal exposure.
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Laringoscopía , Laringe , Humanos , Estudios Prospectivos , Microcirugia , Laringe/cirugía , Cuello/cirugíaRESUMEN
OBJECTIVE: The Laryngoscore was described in 2014 as a practical preoperative assessment tool to predict difficult laryngeal exposure (DLE) during transoral approaches to the larynx. In 2019 the authors proposed a version with a reduced number of variables, called the mini-Laryngoscore. We aim to critically appraise and externally validate these two tools and if needed and possible, to optimize these tools. METHODS: 103 consecutive patients who underwent a microlaryngoscopy between November 2017 and June 2020 at the Leuven University Hospitals were prospectively included and subjected to a presurgical evaluation of 15 parameters and a peroperative scoring of the anterior commissure visualization. Subsequent analysis focused on the concordance of our findings with those of Piazza et al., the discriminatory ability of the test, and the validity of the included items. We then evaluated a modified prediction tool. RESULTS: Of 103 patients, 18 (17.5%) had DLE. The Laryngoscore and mini-Laryngoscore predicted this with a "good" C-index of respectively 0.727 (95%CI: 0.608-0.846) and 0.714 (95%CI: 0.605-0.823). A newly created prediction tool including only three parameters (Interincisors gap, upper jaw dental status and previous treatments) showed a better discriminatory ability (C-index = 0.835, 95%CI: 0.726-0.944) than the original Laryngoscore, a finding that needs further external validation. CONCLUSION: The original Laryngoscore and the mini-Laryngoscore displayed a good discriminative ability. Some parameters can be left out of the Laryngoscore without losing discrimination. An even better prediction model seems possible, using a weighted sum of selected predictor variables and by using the parameters in their continuous form. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:1807-1812, 2024.
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Laringoscopios , Laringe , Humanos , Microcirugia , Laringe/cirugía , Laringoscopía , Hospitales UniversitariosRESUMEN
Adequate visualization of the vocal folds is essential for optimal phonosurgery. Pre-operative knowledge of a difficult laryngeal exposure (DLE) can alert the surgeon regarding the need for alternative measures. Our study is based on the hypothesis that a patient who has difficult intubation (DI) is likely to have DLE, thus scales anticipating DI should also anticipate DLE. Our aims were to correlate patients of actual DI on table with patients who had DLE, secondly to assess the ability of grading scales of DI to predict DLE and finally to obtain a cut-off value of neck circumference and length for predicting DLE. This is a prospective, observational study wherein four grading scales; Modified Mallampati Classification (MMC), 3-3-2, Upper lip bite test (ULBT) and Neck Mobility (NM) were used for anticipating DI and correlated with DLE during MLS. Occurrence of actual DI and DLE was correlated. Neck circumference and neck length was correlated with incidence of DLE. Out of 42 patients, 22 were anticipated to have DI (52.38%). Actual incidence of DI was 6 (14.28%) and DLE was 10 (23.80%). Correlation between actual DI and DLE was statistically significant. Of the 4 grading scales, ULBT was significant in predicting DLE. Neck circumference more than 37.5 cm and neck length less than 15.3 cm was significant in anticipating DLE. There is a significant correlation between DI and DLE. A positive ULBT, neck circumference more than 37.5 cms and neck length less than 15.3 cms are independently suggestive of a DLE.
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OBJECTIVES: In our study, we hypothesized that sternum-mental angle (SMA) was a totally new preoperative predictor of difficult laryngeal exposure (DLE). The main objective of this study was to evaluate the diagnostic utility of SMA in predicting DLE in patients undergoing suspension microlaryngeal surgery, and we also searched for risk factors among the selected parameters. METHODS: A total of 95 patients with vocal cord dysfunction who underwent microlaryngeal surgery were collected. According to the Cormack-Lehane classification method, the patients were divided into non-DLE group (n=73) and DLE group (n=22). Preoperative assessments included age, sex, body mass index (BMI), Modified Mallampati's index (MMI), neck circumference (NC), thyroid-mental distance at neutral position (TMD-NP), TMD at full extension position (TMD-FE), sternum-mental distance at neutral position (SMD-NP), SMD at full extension position (SMD-FE), SMA at neutral position (SMA-NP) and SMA at full extension position (SMA-FE). SMA was defined as the angle between the horizontal line and the line from upper border of the manubrium sterni to mental prominence, and SMA's ability to predict difficult laryngoscopy was compared with that of established predictors. RESULTS: The DLE incidence of the enrolled patients was 23%. Univariate analysis showed that patients in DLE group presented significantly smaller SMA values. SMA-NP less than 13 provided 68.2% sensitivity and 83.6% specificity and SMA-FE less than 22.5 provided 86.4% sensitivity and 80.8% specificity for the detection of DLE. SMA-FE (≤22.5) exhibited the largest area under the curve (AUC: 0.868; 95% CI: 0.784-0.952), confirming its better predictive ability. Binary multivariate logistic regression analyses identified four risk factors including MMI, TMD-FE, TMD-NP which were independently associated with DLE. CONCLUSIONS: SMA is a new and simple predictor with a higher level of efficacy, and could help otorhinolaryngologist plan for managements in patients with DLE.
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Laringe , Microcirugia , Humanos , Intubación Intratraqueal , Laringoscopía/métodos , Laringe/cirugía , Microcirugia/métodos , Estudios Prospectivos , Esternón/cirugíaRESUMEN
Good exposure for visualisation of the glottis is an essential prerequisite for effective microlaryngoscopy. There is no definitive clinical predictor scoring system to predict difficult microlaryngoscopy. The aim of the study was to study the validity of the Laryngoscore scoring system as a preoperative clinical predictor score in Indian population for difficult laryngeal exposure during microlaryngoscopy. A prospective study was carried out in 32 patients undergoing microlaryngoscopy in a tertiary care hospital who were evaluated by a standardized preoperative assessment protocol (Laryngoscore) which included 11 parameters interincisors gap, thyro-mental distance, upper jaw dental status, trismus, mandibular prognathism, macroglossia, micrognathia, degree of neck flexion-extension, history of previous open-neck and/or radiotherapy, Mallampati's modified score, and body mass index. Each parameter was assessed to obtain a total score (Maximum-17). Patients were divided into five classes according to the anterior commissure visualization: class 0 to class IV. Class 0 being complete and class IV being impossible AC visualization. When the Laryngoscore was < 6, good laryngeal exposure was observed in 94% of patients. Laryngoscore had a sensitivity of 87.5% and specificity of 75% in predicting difficult laryngeal exposure. The positive and negative predictive values of the same are 53.8% and 94.7% respectively. Our study found that the Laryngoscore scoring system as a preoperative indicator for predictor of Difficult Laryngeal Exposure during Micro Laryngeal surgeries is very useful in the Indian population.
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Difficult laryngeal exposure during suspension microlaryngoscopic surgeries is a common situation encountered by the phonosurgeons nowadays. It leads to unnecessary trauma, incomplete surgery and even abortion of the procedure. Although various methods have been described to counter the situation, they might not be adequate in some cases with very anteriorly placed larynx. This study is intended to determine the utility of angled rigid endoscope along with malleable endoscopic instruments to improve surgical access in cases with inadequate glottic exposure during suspension microlaryngoscopy. In this cross sectional study conducted at Lokmanya Tilak Municipal Medical College and General Hospital in Mumbai, 50 patients of voice disorders who underwent Suspension Microlaryngoscopy from July 2014 to December 2017 were included. Out of these patients, 5 patients (10%) presented with difficult laryngeal exposure that were operated using readily available angled rigid endoscope along with malleable endoscopic instruments, without requirement of any specially designed instruments. There was improvement in laryngeal exposure in all the cases following utilisation of angled endoscopes. The surgeries were carried out under video monitor guidance with complete excision of the vocal cord lesions. Our study concluded that the cases in which the laryngeal exposure cannot be improved even by various external procedures, can be enhanced by application of angled rigid endoscopes and the vocal cord lesions can be excised completely by using malleable endoscopic instruments.
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OBJECTIVES: Optimal laryngeal exposure during transoral laryngeal surgery is fundamental. We aimed to evaluate the reliability of a recently proposed score (Laryngoscore) in predicting difficult laryngeal exposure (DLE) in an independent cohort of patients undergoing elective microlaryngoscopy. We also verified the relation between DLE, surgeon's expertise, and difficult intubation, and investigated possible areas for score improvement. STUDY DESIGN: Prospective validation study. METHODS: A total of 136 patients were preoperatively evaluated using the Laryngoscore. Patients were divided into three classes according to patient position, type of laryngoscope, and need for external counterpressure to expose the anterior commissure. Based on their mean scores, two groups were identified: good laryngeal exposure (GLE) and DLE. A receiver operating characteristic curve with the Youden index was used to calculate the optimal cutoff value. The χ2 and Fisher exact test were used to correlate GLE and DLE to the surgeon's expertise and difficult intubation. The intraoperative anatomical parameters underlying DLE were also recorded. RESULTS: The optimal cutoff value for differentiating GLE and DLE was 4, which identified 80.6% of DLE cases. No statistically significant difference in GLE and DLE distribution was found between surgeons (P = 0.43). The correlation between difficult intubation and DLE was statistically significant (P = 0.03). The intraoperative parameters determining DLE were epiglottis characteristics (floppy, tight, or short), bulky abdomen and chest, bulky tongue base, mobile teeth, and a narrow laryngeal aditus. CONCLUSION: The Laryngoscore is reliable for detecting DLE preoperatively. The inclusion of additional parameters may allow a more complete assessment and maximize its diagnostic accuracy. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:1438-1443, 2019.
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Enfermedades de la Laringe/diagnóstico , Laringoscopía/estadística & datos numéricos , Laringe/patología , Microcirugia/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Adulto , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Procedimientos Quirúrgicos Electivos , Diseño de Equipo , Femenino , Humanos , Intubación Intratraqueal/estadística & datos numéricos , Enfermedades de la Laringe/patología , Enfermedades de la Laringe/cirugía , Laringoscopía/métodos , Laringe/cirugía , Masculino , Microcirugia/métodos , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Periodo Preoperatorio , Estudios Prospectivos , Curva ROC , Valores de Referencia , Reproducibilidad de los Resultados , Adulto JovenRESUMEN
The optimal treatments of carcinoma in situ of glottis include radiotherapy, laser surgery and vertical partial laryngectomy. Conventional surgical treatments need general anesthesia and radiotherapy has several complications. Recently, the effectiveness of 532 nm potassium titanyl phosphate (KTP) laser has been proven and widely used in vocal fold diseases even some cases of vocal fold dysplasia. A patient with difficult laryngeal exposure underwent fiberoptic laryngeal laser surgery using KTP laser under local anesthesia, showed improved voice outcome and the glottic lesion was removed successfully without local recurrence and regional metastasis 18 months after surgery.
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Humanos , Anestesia General , Anestesia Local , Carcinoma in Situ , Glotis , Laringectomía , Terapia por Láser , Láseres de Estado Sólido , Metástasis de la Neoplasia , Potasio , Radioterapia , Recurrencia , Pliegues Vocales , VozRESUMEN
OBJECTIVE: This study aimed to investigate the pressure distribution during direct microlaryngoscopy and its relation with the positioning of the patient. STUDY DESIGN: This is a prospective study in cadavers. MATERIALS AND METHODS: The pressure distribution during direct microlaryngoscopy was investigated in five adult fresh cadavers by using matrix-based piezoresistive thin-film sensors. The pressure among three head and neck positions (extension-extension, neutral, and flexion-extension) was studied. RESULTS: The real-time pressure and its distribution were recorded as 3-D contours. The map commonly showed two peak pressure points, with one focused on the middle of the laryngoscope (peak pressure 1) and the other one focused on the distal part of the laryngoscope (peak pressure 2). The mean average pressure in this study was 38 ± 13 kPa, and the flexion-extension position had the lowest average pressure and peak pressure. However, the average pressure and peak pressure 1 showed no significant difference among the three positions (P > 0.05); peak pressure 2 in the flexion-extension position was significantly lower than that in the extension-extension position (P = 0.024) and the neutral position (P = 0.020). CONCLUSIONS: The results of this study indicate that the flexion-extension position induced lower pressure exerted on the laryngoscope and is an optimal position for direct microlaryngoscopy. Hyoid bone may play an important role in the pressure exerted.
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Laringoscopía/instrumentación , Anciano , Femenino , Humanos , Laringoscopía/métodos , Masculino , Persona de Mediana Edad , Presión , Estudios ProspectivosRESUMEN
CONCLUSION: Airtraq® laryngoscope can obviously improve laryngeal visualization and may provide a useful solution to treatment of patients with difficult laryngeal exposure (DLE) under a conventional suspension laryngoscope in phonomicrosurgery. OBJECTIVE: In phonomicrosurgery, otolaryngologists may inevitably encounter DLE. Attempts to improve laryngeal exposure have yielded important advances, but the prevalence of DLE yet remains persistent. To overcome this problem, this study applied the Airtraq® laryngoscope to perform phonomicrosurgery combined with a video system. The aim of this study is, thus, to explore the clinical usefulness of the Airtraq® laryngoscope in patients with DLE. METHODS: One hundred and fifty-eight cases who underwent phonomicrosurgery for benign lesions of vocal cord at this hospital were enrolled in this study, of which nine patients were confirmed to be DLE under direct suspension laryngoscope. These nine patients were treated by Airtraq® laryngoscope together with a video system. RESULTS: In comparison with the traditional suspension laryngoscope, exposure of larynx was remarkably improved by Airtraq® laryngoscope. Under the excellent laryngeal visualization provided by Airtraq®, phonomicrosurgery was successfully accomplished for vocal fold lesions without any severe complications in all cases with DLE.
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Laringoscopios , Microcirugia/instrumentación , Pliegues Vocales/cirugía , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
The aim of the present study was to identify preoperative clinical predictors for difficult laryngeal exposure (DLE) and to define a simple grading system for laryngeal exposure. This is a prospective descriptive study carried out in a tertiary teaching hospital in South India. Patients above 18 years undergoing microlaryngoscopy had presurgical evaluation of 11 physical parameters. Grading of Modified Cormack-Lehane Score (MCLS) and rigid laryngoscopy were done during procedure. On logistic regression analysis, with a 95 % confidence interval (CI) MCLS was found to be a statistically significant predictor (odds ratio 12). With 90 % CI, neck circumference, atlanto-occipital extension and MCLS were significant (odds ratio of 4, 4, 12 respectively). Neck circumference of more than 34.25 cm and limited atlanto-occipital extension of less than 19.50, predicts difficult laryngeal exposure. A simple grading system for laryngeal exposure during microlaryngoscopy is being proposed. MCLS grade more than 2a done intra operatively correlates well with difficult intubation.
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Objective:This paper seeks to identify useful and reliable indicators for predicting the occurrence of difficult laryngeal exposure(DLE) in microlaryngosurgery.Method:Sixty-two patients were given physical examinations,including 4 general parameters:age,sex,BMI,and MMI,and 14 physical measurement parameters(TA,UIA,LIA,IG,LIMD,MA,MCD,MH,MDI,HMD,TMD,SMD,TMA,THUIA).Univariate analysis,stepwise regression analysis and ROC curve analysis were employed to identify parameters with the potential to predict DLE.Result:We found sex(P<0.05) showed significant correlation with the laryngeal exposure score(P<0.05).We also found LIMD,MA,TMA and THUIA to be reliable DLE predictors.The cutoff values for predicting DLE were LIMD>4.53cm,MA>115.5°,TMA>99.2°,and THUIA>152.6°.Conclusion:X-ray measurement predictors of LIMD,MA,TMA,and THUIA before operation are important for the prediction of DLE.Sex is also the reliable DLE predictor.Males were prone to DLE.
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Laringe/cirugía , Humanos , Laringe/anatomía & histología , Laringe/diagnóstico por imagen , Masculino , Curva ROC , Radiografía , Análisis de Regresión , Rayos XRESUMEN
OBJECTIVES/HYPOTHESIS: To identify a clinical predictor score for difficult laryngeal exposure (DLE) during operative microlaryngoscopy. STUDY DESIGN: Prospective cohort study in two academic institutions. METHODS: We evaluated 319 patients before microlaryngoscopy for benign and malignant glottic diseases by a standardized preoperative assessment protocol (Laryngoscore) that included 11 parameters: interincisors gap (IIG), thyro-mental distance, upper jaw dental status, trismus, mandibular prognathism, macroglossia, micrognathia, degree of neck flexion-extension, history of previous open-neck and/or radiotherapy, Mallampati's modified score, and body mass index (BMI). Each parameter was assessed to obtain a total score. Patients were divided into five classes according to the anterior commissure (AC) visualization: class 0, complete AC visualization with large-bore laryngoscopes in the Boyce-Jackson position; class I, as class 0 with external laryngeal counterpressure; class II, as class I in the flexion-flexion position; class III, as class II using small-bore laryngoscopes; and class IV, impossible AC visualization. RESULTS: Class 0-I-II (good/acceptable laryngeal exposure) presented a median score < 6. This value was chosen as cutoff for distinguishing favorable versus difficult/impossible laryngeal exposures. When the Laryngoscore was < 6, good laryngeal exposure was observed in 94% of patients, whereas when ≥ 6, DLE was encountered in 40%. When considering a Laryngoscore of ≥ 9, 67% of patients had a DLE. At univariate analysis, IIG, upper jaw dental status, macroglossia, micrognathia, degree of neck flexion-extension, and BMI statistically impacted on DLE (P < 0.05). CONCLUSIONS: The Laryngoscore is a good predictor of DLE and assists in selecting the ideal candidates for operative microlaryngoscopy. LEVEL OF EVIDENCE: 2b.