Clinical characteristics of laryngeal versus nonlaryngeal amyloidosis

Laryngotracheal Amyloidosis: Amyloid Airway Center 23-Year Experience

OBJECTIVES

Localized laryngotracheal amyloidosis (LA) is a rare disease that can impact phonation and respiration. Treatment options include observation, surgery, and radiation therapy (RT). Given the rare incidence of LA, evidence regarding optimal management and long-term outcomes is limited.

STUDY DESIGN

Retrospective cross-sectional analysis.

METHODS

All patients with LA presenting to an international amyloid center from 1999 to 2022 were analyzed. Patients were categorized by treatment modality: surgery, RT, or observation. Patient and disease factors including demographics, clinical presentation, and progression with need for additional treatment were evaluated.

RESULTS

Seventy-one patients (27M:44F) with LA were treated with surgery (n = 40), RT (n = 11), and observation (n = 20). Gender distribution, age at diagnosis, and systemic workup did not differ significantly between treatment cohorts. A correlation was identified between LA location and treatment modality, with higher rate of subglottic/tracheal amyloid in RT patients vs. surgery and observation patients [(90% and 52% respectively), p < 0.005]. Surgery patients had a median of two surgeries for disease management (range: 1-32) and RT patients had median five surgeries prior to RT (range: 0-17). Six patients required tracheotomy: 3/40 surgery, 3/11 RT and 0/20 in observation cohort. Surgery and RT patients had a longer duration of follow-up (mean 6.7 and 11.7 years) compared with the observation cohort (5.7 years).

CONCLUSION

Laryngotracheal amyloidosis is a rare disease with variable presentation. Selective surgery of involved subsites is the primary treatment, though multiple surgeries may be needed to optimize function. Observation is appropriate for those with minimal symptoms. For recalcitrant disease, and particularly subglottic/tracheal amyloid, radiotherapy can be beneficial.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1606-1613, 2024.

Laryngeal Amyloidosis: What is the Role of Imaging?

OBJECTIVE/HYPOTHESIS

To review the imaging findings of laryngeal amyloidosis and to identify radiological findings suggestive of this disease.

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective chart review of patients with pathologically confirmed laryngeal amyloidosis was performed from 2009 to 2022. Clinical and demographic factors were collected. A fellowship-trained head and neck radiologist reviewed all computed tomography (CT) scans and magnetic resonance imaging (MRI) findings within this cohort.

RESULTS

12 patients were identified and a total of 36 imaging studies analyzed. Localized amyloidosis was found in the supraglottic region (n = 6), glottic region (n = 7), and subglottic region (n = 5); six patients had disease spanning two subsites. The most common finding on the CT scan was a homogeneous and well-defined submucosal soft tissue mass. Punctate calcifications were present in three cases. The presence of contrast enhancement was identified in the majority of patients who underwent MRI (4/5). MRI showed consistent signal intensity, hypointense, or isointense on both T1-weighted and T2-weighted images. Diffusion-weighted sequences were obtained in every patient and did not demonstrate diffusion restriction.

CONCLUSION

This is the largest series searching for unifying imaging characteristics of laryngeal amyloidosis. This research suggests that characteristics from CT and MR provide both similar and unique features of laryngeal amyloidosis on imaging. Both modalities identify a submucosal mass. CT is the preferred modality to demonstrate punctate calcifications, while MRI identifies enhancement and altered signal characteristics. The main benefit of serial imaging is the correlation with patient symptoms, identification of the extent of disease, and assisting in delineating appropriate timing for surgery.

Amyloid Deposition in the Upper Aerodigestive Tract, A Single Institute Experience

Objectives: The purpose of this study is to evaluate clinical information, laboratory results, and pathologic findings of patients with amyloidosis involving larynx, oral cavity, and pharynx from our institute. Methods: A total of 39 specimens from 28 patients were retrieved from 2000 to 2020. Data collection included clinical presentation, radiographic, laboratory results, and pathologic findings. Results: A total of 12 patients had laryngeal amyloidosis and true vocal cord was the most common location. Protein electrophoresis detected monoclonal protein in 10% (1/10) of patients tested. Two patients had hematopoietic disorder (2/12, 17%) and another patient had a peptide profile consistent with amyloid transthyretin (ATTR) detected by mass spectrometry. Twelve patients showed amyloidosis in the oral cavity with 75% involving the tongue. Monoclonal protein was found in 89% of cases tested. Nine patients (9/12, 75%) had systematic involvement including 6 with hematopoietic malignancy and 3 with biopsy-confirmed systemic light chain amyloidosis. Compared to the laryngeal amyloidosis, amyloid deposition in oral cavity had a significant higher association with systematic disease (P < .01). Pharyngeal amyloidosis was seen in 7 patients. Three of 6 patients tested (3/6, 50%) were found to have biopsy-confirmed hematopoietic malignancy. Conclusions: Laryngeal amyloidosis is mostly a localized disease. Amyloidosis involving oral cavity is associated with significantly higher risk of systematic involvement which warrants a comprehensive laboratory, radiographic, and pathologic workup. There is limited data about pharynx amyloidosis. Oropharynx and hypopharynx amyloidosis appear to be more likely associated with underlying hematologic malignancy compared to nasopharynx involvement.

Surgical treatment of laryngeal amyloidosis: a systematic review

PURPOSE

The aim of this review was to study the surgical management of laryngeal amyloidosis and estimate the rate of recurrence after surgery.

METHODS

A systematic review searching PubMed and EMBASE was performed. A qualitative synthesis of data regarding the surgical management of LA and a quantitative analysis of the recurrence rate after surgery was conducted.

RESULTS

This systematic review included 14 retrospective studies, one of whom is retrospective controlled. A total of 515 subjects were included, the mean age ranged from 43.3 to 58 years with a male-to-female ratio of 1:1.3. All cases had a localized laryngeal amyloidosis. The supraglottic region was the most affected laryngeal site and multiple sites were commonly involved. Surgical treatment consists of endoscopic excision using laser, cold or powered instruments. Open surgery is required for severe primary case or revision surgery. Surgical complications such as granulomatosis scar tissue formation, tracheostomy, laryngotracheal stenosis, pneumothorax and concomitant malignancy were developed in 17.5% of patients. The time onset to diagnosis varied from 1 months to 15 years and the duration of follow-up from 3 months to 25 years. The rate of recurrence was 28.4% (95% CI 24.5-32.6) and the timing of recurrences ranged from 3 months to 10 years.

CONCLUSION

The recurrence rate after primary surgery for laryngeal amyloidosis is high. A tailored surgical treatment based on the disease extension and a long-term follow up are recommended.

Laryngotracheobronchial Amyloidosis: Patterns of Presentation and Management

OBJECTIVE

To evaluate the pattern of presentation and management of laryngotracheobronchial amyloidosis at a tertiary care academic center over a 27 year period.

METHODS

In a retrospective review, the electronic medical record at a tertiary care academic center was queried for encounters with 3 laryngologists between 1996 and 2019 which included the ICD-9 or ICD-10 diagnosis of amyloidosis. Demographics, clinical presentation, referral diagnoses, medical history, family history, laboratory values, radiology studies, and treatment modalities of subjects were collated. Results were analyzed using standard univariate descriptive statistics.

RESULTS

Seventeen subjects were identified with an average age at diagnosis of 58 years (range 26-76 years). The most common amyloid type on biopsy was immunoglobulin light chain (AL) subtype. The most common location of laryngeal amyloid at diagnosis was the glottis and disease was more likely to be bilateral at the time of diagnosis in this location. Supraglottic disease more often had a unilateral presentation and had a tendency to spread to additional laryngeal subsites. Nearly 25% of subjects had associated systemic disease, including multiple myeloma, auto-immune disease, and familial ATTR mutation.

CONCLUSIONS

The overall rate of associated systemic disease was low in our study cohort; however, it is higher than typically referenced in extant literature. Our cohort demonstrates that while laryngeal amyloidosis is a chronic condition, the behavior is generally indolent with a low treatment burden.

One Hundred Cases of Localized Laryngeal Amyloidosis - Evidence for Future Management

OBJECTIVE/HYPOTHESIS

To update the current understanding of localized laryngeal amyloidosis by analyzing the NHS National Amyloidosis Database and to further clarify the important ongoing management issues.

STUDY DESIGN

Retrospective review, case series.

METHODS

Patients with laryngeal amyloid were identified from the database of the NHS National Amyloidosis Center, UCL, Royal Free Hospital, London between 2000 and 2017. Patient demographics and disease profile were collated, including the exact location of amyloid deposit, treatments if any, and progression of disease.

RESULTS

One hundred and three patients with localized laryngeal amyloid where identified from the database, with a mean age of 54 at diagnosis and female to male ratio of 54:49. Three patients were excluded from further analysis due to limited database information. The majority of amyloid was found in either the supraglottis (44) or glottis (53) but all the laryngeal subsites were involved. One-third of the patients (34) had amyloid in more than one laryngeal subsite. No patients were found to progress to systemic amyloid, but many progressed locally to other subsites or further down the LTB tree (29%). Three patients were successfully treated with radiotherapy after other modalities had failed.

CONCLUSIONS

This is the largest case series reported to date of localized laryngeal amyloidosis. It highlights the high incidence of multifocal disease and the significant proportion of patients who progressed, not to systemic amyloidosis but to more extensive localized amyloid. We recommend that in all cases of laryngeal amyloid, patients should undergo a thorough assessment of the upper and lower airways and have ongoing surveillance for at least 15 years.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1912-E1917, 2021.

Amyloidosis in the head and neck: CT findings with clinicopathological correlation

PURPOSE

To characterize the CT imaging features of head and neck amyloidosis and correlate with extent of disease and clinical outcomes.

MATERIALS AND METHODS

This retrospective study included 80 patients with head and neck amyloidosis who underwent soft tissue neck CT imaging between November 2003 and April 2018. The CT imaging features including lesion distribution, morphology (focal, diffuse/circumferential, or combined), presence and pattern of calcification, (punctate or diffuse), and thickness of airway lesion were evaluated and compared with the extent of amyloidosis (localized or systemic), and clinical course (stable, no recurrence, or progression requiring repeated surgical treatment).

RESULTS

Localized disease (83.8%, 67/80) was most common with AL type (97.6%, 41/42) representing nearly all cases of head and neck amyloidosis. The larynx was the most frequently affected organ (60.0%, 48/80), specifically the glottis (43.8%, 35/80). Calcification was seen in 65.0% of cases (52/80). Non-airway or tongue lesions were significantly associated with systemic (92.3%, 12/13) as opposed to localized amyloidosis (4.5%, 3/67; P < 0.001). Repeated surgical treatment was significantly associated with laryngeal amyloidosis (35.3%, 12/34; P = 0.002) and multi-centric disease (33.3%, 10/30; P = 0.048). Airway wall thickness in patients who required repeated surgical treatment was significantly greater than in patients with stable or no recurrent disease (P = 0.016).

CONCLUSION

Knowledge of the imaging features of head and neck amyloidosis can aid the diagnosis, disease monitoring, and prediction of patients requiring repeated surgical intervention.

Clinical Profile of Patients with Head and Neck Amyloidosis: A Single-Institution Retrospective Chart Review

Introduction  Isolated amyloidosis involving the head and neck is a rare entity. The pathophysiology of the localized disease appears to be distinct from that of the systemic counterpart. Systemic progression of the localized disease is unusual, and the prognosis of the localized form is excellent.

Objective  To describe the demographic and clinicopathological characteristics of patients presenting with localized head and neck subsite amyloidosis.

Methods  A retrospective chart review of the patients with head and neck amyloidosis identified by the electronic search of the electronic database of the Departments of Pathology and Otorhinolaryngology was performed. The various demographic and clinical data were tabulated.

Results  In total, seven patients (four females, three males) with localized head and neck amyloidosis (three supraglottic, three lingual and one sinonasal) were identified. Six patients had AL-amyloid deposits, and one patient had AA-amyloid deposits. Supraglottic involvement and that of the base of the tongue were treated surgically using CO2 laser, and these patients were disease-free at the last follow-up. The patient with sinonasal amyloidosis experienced symptom recurrence after six months of the functional endoscopic sinus surgery. All of the patients were screened for systemic amyloidosis with abdominal fat pad biopsy, and were found to be free of systemic spread.

Conclusion  Isolated head and neck amyloidosis, as opposed to systemic amyloidosis, has an excellent prognosis in terms of survival. Therefore, systemic amyloidosis should be excluded in all cases. The treatment of choice remains surgical excision; however, watchful waiting may be a suitable strategy for mild symptoms or for cases in which the disease was discovered incidentally.

A radiologic review of hoarse voice from anatomic and neurologic perspectives

The differential diagnosis for hoarseness is extensive and includes a multitude of etiologies that span a large geographic area from the brainstem to the mediastinum. Therefore, localizing a causative lesion can be extremely difficult for clinicians and radiologists alike. In this review, we will first discuss the normal anatomy of the larynx and its innervation via the vagus and recurrent laryngeal nerves. We will then proceed with a guided tour of the various infectious/inflammatory, neoplastic, congenital, and traumatic/iatrogenic causes of hoarseness subdivided by anatomic location (brainstem, skull base, carotid sheath, thyroid, larynx, and superior mediastinum). Along the way, we will discuss the various cross-sectional imaging modalities best suited to detect the often subtle signs of recurrent laryngeal nerve injury. With thorough knowledge of these entities, radiologists can impact patient care by suggesting the appropriate imaging test and tailoring their search patterns to detect the subtle findings of laryngeal dysfunction.

[A case report of amyloidosis of the larynx in a 13-year-old girl]

Amyloidosis of the larynx is rare in the pediatric age group. We present a clinical case of laryngeal amyloidosis manifesting as false vocal fold bulging in a thirteen-year-old girl with hoarseness and with initial suspicion of laryngeal tumor. Computed tomography and ultrasound scanning of the larynx were useful in determining the laryngeal process size along with fibro laryngoscopy. There was performed a microsurgical removal of the larynx formation. The results of Congo red staining of the formation were characteristic of amyloid. Systemic manifestations of the disease were not revealed.

Multifocal head and neck amyloidosis as a diagnostic clue of systemic lupus erythematosus (SLE): A case report

RATIONALE

Amyloidosis accounts for 2% of head and neck tumors. Amyloidosis that develops in the head and neck region is localized amyloidosis. Multifocal amyloidosis in the head and neck region is extremely rare.

PATIENT CONCERNS

The patient presented to the clinic of otolaryngology with nasal obstruction, anosmia and left neck mass for several months.

DIAGNOSIS

A left nasopharynx tumor was revealed under nasopharyngeal scope. Eosinophilic, proteinaceous material was revealed under a pathology scope in the nasopharynx tissue and neck tumor. Congo red staining demonstrated pale congophilic amorphous material with apple-green birefringence under cross-polarized light, and multifocal amyloidosis was diagnosed. Amyloidosis secondary to systemic lupus erythematosus (SLE) was confirmed after a series of investigations.

INTERVENTIONS

The patient underwent local excision for multifocal amyloidosis without following management. To control underlying SLE, the patient accepted steroid pulse therapy and immunosuppressants. The patient eventually achieved disease remission.

OUTCOMES

During the 6 months of follow-up in the outpatient department of otolaryngology and rheumatology, complications, recurrence of nasopharyngeal amyloidosis, and SLE flare-up were not observed.

LESSONS

Head and neck amyloidosis involving the nasopharynx is a rare presentation of this disease. Head and neck multifocal amyloidosis should be taken as a hint of systemic disease. In head and neck amyloidosis, a comprehensive survey should be performed to clarify the underlying disease predisposing to amyloidosis and organ involvement.

Identification and Management of Chronic Laryngitis

Chronic laryngitis is an inflammatory process of at least 3 weeks duration and affects phonation, breathing, and swallowing. This article describes the infectious, inflammatory, and autoimmune causes of chronic laryngitis. Symptoms of chronic laryngitis are nonspecific and may range from mild to airway compromise requiring emergent tracheostomy.