Localized Laryngeal Amyloidosis, A Report of a Case with a Review of the Literature

Oral localized amyloidosis

This report describes two cases of oral localized amyloidosis (LA). In case 1, a 52-year-old man appeared with painful slightly, yellowish multiple nodules located on the dorsum of the tongue, of unknown duration. Incisional biopsy was performed, and the histopathologic analysis revealed a homogeneous, eosinophilic, and extracellular material. Congo red stain showed salmon pink coloration at light microscopy and apple-green birefringence at polarized light. In case 2, a 74-year-old man presented asymptomatic nodular lesions on the labial commissures with duration of several months. An excisional biopsy was performed in both lesions, and microscopically the specimen demonstrated the same histopathologic features of the case 1. Furthermore, amyloidosis with systemic involvement was excluded after investigations for both patients. Thus, the final diagnosis for both cases was LA. The patient 1 refused the surgical excision of the residual lesion, and in both cases, no signs of clinical and systemic progression were observed after 24 and 84 months of follow up. Although it is rare, LA should be considered in the differential diagnosis of multiple or single yellowish nodules on the oral cavity.

Endoscopic Treatment of Amyloidosis of the Nasopharynx

Amyloidosis of the nasopharynx is a rare presentation of localized amyloidosis. The majority of systemic amyloidosis cases involve the heart, gastrointestinal tract, kidneys, and upper and lower respiratory tract. Localized amyloidosis involving only one site is less common, but has been observed in the head and neck area, particularly in the larynx or the oral cavity. Amyloidosis in the nasopharynx has been reported in only seven previous cases in the English literature.

Amyloidosis and the lung

Amyloidosis is a disorder of protein folding in which normally soluble plasma proteins aggregate in an abnormal fibrillar form causing progressive disruption to tissue structure and organ function. This review covers systemic AA and AL amyloidosis which may arise as a consequence of chronic respiratory conditions; the manifestations of both systemic and of localised amyloid deposition within the respiratory tract and provides a summary of current approaches to diagnosis and management.

Tracheobronchial Amyloidosis in a Patient with Sjögren's Syndrome

A 65-year-old woman was referred to our respiratory department because of incidentally detected endobronchial deposits. She had been diagnosed with Sjögren's syndrome 12 years earlier. Bronchoscopy showed protrusion of the reddened, shiny or edematous mucosa at the orifice of the lower lobe bronchus, suggesting a submucosal tumor. Based on the pathological findings of the transbronchial biopsied specimens, the patient was diagnosed with non-classified type tracheobronchial amyloidosis associated with Sjögren's syndrome, which was negative for both λ and κ chains, transthyretin and amyloid A. She has remained in good health without a relapse of the tumor.

Localized Tongue Amyloidosis

Objective

Review Mayo Clinic experience of localized tongue amyloidosis.

Study Design

Case series with retrospective chart review.

Setting

Academic medical center.

Subjects and Methods

Cases of localized tongue amyloidosis were identified from the dysproteinemia database at the Mayo Clinic in Rochester, Minnesota. Electronic records were reviewed with focus on presenting symptoms, laboratory results (ie, serum or urine immunoelectrophoresis, bone marrow biopsy, and fat aspirate analysis), treatment modality, and status of disease at follow-up.

Results

Six cases of localized tongue amyloidosis presented to the Mayo Clinic between 1969 and 2011. Mean patient age was 69 years (range, 43-90). Patients presented with asymptomatic tongue mass(es). Biopsy of the tongue mass in all patients showed amyloid on Congo red stains. Work-up for systemic amyloidosis, including bone marrow biopsy, fat aspiration, and serum and urine protein immunoelectrophoresis, was negative for all 6 patients, nor was there other organ involvement. Two patients underwent resection of the lesions, and the remaining patients elected for observation. Recurrence requiring repeat excision occurred in 1 of the patients that underwent resection. Repeat evaluation for systemic involvement was performed in 3 patients 1 to 3 years after the initial diagnosis. None of these patients went on to develop systemic involvement.

Conclusions

Localized tongue amyloidosis remains a rare diagnosis and requires exclusion of systemic involvement. Localized lesions may be observed or resected; however, recurrence may occur with resection. Patients with localized tongue amyloidosis do not appear to be at increased risk of developing systemic involvement.

A retrospective case review of isolated sinonasal amyloidosis

OBJECTIVE

We report an extremely rare case of isolated primary sinonasal amyloidosis.

METHOD

A case report and comprehensive literature review are presented. Common symptoms, signs and treatment options are examined, and used to derive an algorithm with which the practising otolaryngologist can diagnose and manage this condition.

RESULTS

Only 15 cases of true primary idiopathic amyloid restricted to the sinonasal tract have previously been reported. Isolated sinonasal amyloid presents with common rhinological symptoms which mimic chronic rhinosinusitis, i.e. nasal obstruction, nasal discharge, epistaxis, 'glue ear' and post-nasal drip. The lesion itself can appear as a simple inflammatory polyp. In children, the symptoms are easily attributed to enlarged adenoids. Although there is a concern that surgically induced trauma to the paranasal mucosa might incite reactive amyloid deposition, this seems not to be the case, and surgery provides symptomatic relief in the majority of patients.

CONCLUSION

This article is the first to report the characteristic features of isolated primary sinonasal amyloidosis. The evidence suggests that meticulous surgery can produce substantial symptomatic improvement in these patients.

Laryngeal amyloidosis with laryngocele

Both laryngocele and laryngeal amyloidosis are uncommon, and simultaneous occurrences of these entities are extremely rare. A case of laryngeal amyloidosis with laryngocele in which the computed tomography (CT) and magnetic resonance (MR) imaging of the larynx, clearly demonstrating both disease processes, is discussed. Diagnosis is confirmed by histopathologic specimens. Only two cases have been reported in the world literature, and this is the third case of laryngeal amyloidosis associated with laryngocele.

Laryngeal amyloidosis in 10 patients

OBJECTIVES

Review the location, symptoms, treatment, and outcomes in 10 consecutive laryngeal amyloid (LA) patients.

STUDY DESIGN

Pre and retrospective evaluation after treatment.

METHODS

Analysis of visual and phonatory pathology and detailed description of surgery.

RESULTS

Amyloid on the undersurface of both true vocal cords (TVCs) was found in two cases, uni- or bilaterally submucosally in the false vocal cords (FVCs) in eight cases, extending down into the lateral TVC in four cases, or on the undersurface of the TVCs as well in one case. The chief complaint was hoarseness and not shortness of breath. The amyloid was resected with a CO2 laser by way of microdirect laryngoscopy (MDL) on one side at a time to try to prevent anterior commissure scarring. Removal of most of the FVC improved the voice, but removal of the whole FVC to the inner thyroid perichondrium was found to be necessary to avoid recurrence from supraglottic deposits. Removal of at least 2 mm of the upper edge of a 3 to 4 mm thick submucosal deposit to the thyroarytenoid (TA) muscle along with the overlying mucosa on at least one side was necessary to improve hoarseness when amyloid was present on the undersurface of both TVCs. Partial regrowth occurred in a few months to years after partial removal. Seven patients had had one to seven prior removals. Any hard amyloid in the lateral TVC (floor of ventricle) as an inferior extension from FVC amyloid needed to be at least partially removed to avoid hoarseness from a convex vocal cord. The voice improved postoperatively in all patients. Follow-up after the first operation was 6 months to 16 years, with an average of 6.5 years. Four FVC patients required re-excision on the same side after the first operation, but none has required a third removal as of yet.

Amyloid Tumor of the Larynx associated with Plasma Cell Infiltration: Differential Diagnosis

Localized amyloidosis of the larynx is uncommon, accounting for fewer than 1 % of all benign laryngeal tumors. We report 2 cases of laryngeal amyloidosis in which dense plasma cell infiltrates were found in the vicinity of the amyloid deposits; in view of this finding, we suspected a hematologic disease—plasmacytoma in particular. However, molecular genetic analysis did not demonstrate any light-chain restriction, indicating that the plasma cells were of polyclonal origin and therefore consistent with chronic inflammation. We also discuss the available literature with respect to diagnostic and therapeutic procedures inpatients with amyloidosis of the upper airway.

Localized amyloidosis of the tongue: a review

Amyloidosis is a disease entity defined by the presence of extracellular deposits of proteinacious material. These deposits have a characteristic apple-green birefringence with polarized light after staining with Congo red. Amyloid involvement of the tongue is almost universally secondary to systemic disease. The mean survival of patients with a systemic form of amyloidosis is between 5 to 15 months, whereas those with the localized form have an excellent prognosis. This article presents a case of the more unusual localized form. A thorough evaluation, including abdominal fat or rectal biopsy, is essential in every patient to identify any systemic involvement. The absence of systemic amyloidosis offers a much more favorable prognosis and may be treated with simple surgical excision.

Amyloidosis of the upper aerodigestive tract

OBJECTIVES/HYPOTHESIS

To delineate the clinical and pathologic characteristics of upper aerodigestive tract amyloidosis with particular attention to laryngeal amyloidosis.

STUDY DESIGN

Retrospective chart review of patients with amyloidosis of Thomas Jefferson University and its affiliated hospitals.

MATERIAL AND METHODS

The charts of 16 patients with upper aerodigestive tract amyloidosis identified from the databases of the Thomas Jefferson University pathology department were reviewed and included in the study.

RESULTS

Sixteen patients (9 male and 7 female, with an average age of 49.8 years) with upper aerodigestive tract amyloidosis were identified. The most common site of amyloid involvement was the larynx. Consequently, patients most commonly presented with hoarseness (14 of 16). All patients underwent surgical removal of the amyloid deposits. Fourteen patients had primary localized amyloidosis. Two experienced systemic involvement. Seven of the 16 patients developed recurrences requiring further treatment.

CONCLUSIONS

Amyloidosis of the upper aerodigestive tract generally behaves as a benign, localized condition treatable by surgical resection. Regular follow-up with laryngoscopy is indicated for early diagnosis of recurrence, and multiple surgical procedures may be required to control symptoms.

Localized laryngotracheobronchial amyloidosis: Case report and review of the literature

Although localized laryngotracheobronchial amyloidosis is rare, the otolaryngologist–head and neck surgeon should be familiar with this condition. Its characteristic appearance can suggest its presence in a patient who has the typical initial symptoms. Biopsies during direct laryngoscopy and bronchoscopy can play both a diagnostic and therapeutic role. After an appropriate examination to rule out systemic involvement, the patient should be managed with conservative surgery, although the use of a CO2 laser might be more efficacious than conventional surgery. With appropriate diagnosis and treatment, patients should expect a favorable prognosis. In this article, we describe a new case of localized laryngotracheobronchial amyloidosis in a 67-year-old woman, and we review the literature on this subject.

CT and MR imaging of localized amyloidosis

The localized form of amyloidosis affecting the head and neck region is rare. The characteristic features of localized amyloidosis appeared as multiple nodules on the tongue, lip, and cheek on computed tomography (CT) and magnetic resonance imaging (MRI). Contrast-enhanced CT scans represented this lesion as a marked nodular enhancement. MR features of this lesion appeared slightly low on T1-weighted images and slightly high on T2-weighted images compared with T1-T2 images of residual normal tongue. Time contrast intensity curves obtained from dynamic MRI rapidly increased to reach a plateau and gradually decreased during the late and delayed phases. MR findings suggest that such lesions might be comprised of fibrous tissue with abundant vessels. This report suggests that dynamic MRI might be helpful for diagnosing localized amyloidosis.

Amyloidoma of the nose in a pediatric patient: a case report

Localized amyloidosis in the head and neck is a rare and benign disease. Larynx is the most common site of involvement and accounts for 0.2% to 1.5% of benign laryngeal tumors. The oral cavity and pharynx may also be involved in localized amyloidosis of the head and neck. There are only 7 cases of localized nasopharyngeal amyloidosis, and 8 cases of localized nasal amyloidosis reported to date. Out of these 8 cases of nasal amyloidosis, only 1 of them is a pediatric patient. We present the second reported case of localized nasal amyloidosis in a pediatric patient. This case report describes a 10-year-old girl with a 1-year history of right-sided nasal obstruction and mucoid discharge. Examination revealed an irregular erythematous, waxy gray mass arising from the right inferior turbinate. Computed tomography and magnetic resonance imaging showed the mass arising from the inferior turbinates, whereas other investigations excluded systemic amyloidosis. Histology from surgical excision revealed amyloidosis. This case illustrates that although amyloidoma of the nose is rare, it should also be considered as part of the differentials of a nasal mass even in pediatric patients. [Editorial comment: These authors demonstrate that an index of suspicion and confirmation of that suspicion through biopsy and subsequent pathologic evaluations Maybe the only way to avoid missing this potentially important cause of nasal obstruction.]

[Laryngeal amyloidosis: a rare cause of hoarseness]

INTRODUCTION

The larynx is a rare site of deposition for amyloidosis. Diagnosis may be delayed and evoked in patients with prolonged hoarseness. We have reported two cases of laryngeal amyloidosis.

EXEGESIS

One man and one woman suffered from hoarseness during one and three years, respectively. Laryngoscopic examination showed diffuse infiltration of the larynx. Amyloidosis was confirmed by the characteristic Congo-red staining of laryngeal biopsies. The search for other localizations of amyloidosis was negative. No monoclonal plasma cell proliferation was detected. Both patients received endoscopic CO2 laser excision. In one case, chemotherapy was initially associated due to dystrophic plasma cells in bone marrow aspiration and then withdrawn because of clinical failure. With a 6-month follow-up, hoarseness remained stable.

CONCLUSION

Laryngeal amyloidosis is an essentially localized disease revealed by hoarseness. Treatment is endoscopic by laser excision. In nearly half of the cases in the literature, it had to be repeated due to localized recurrent lesions. Long-term prognosis of localized laryngeal amyloidosis is better than systemic AL amyloidosis.

Amyloidosis of the larynx: a clinicopathologic study of 11 cases

Laryngeal amyloidosis (LA) is uncommon and poorly understood, with limited long-term clinicopathologic and immunophenotypic studies in the literature. Eleven cases of LA were retrieved from the files of the Otorhinolaryngic-Head & Neck Tumor Registry from 1953 to 1990. The histology, histochemistry, immunohistochemistry, and follow-up were reviewed. All patients (three women and eight men) presented with hoarseness at an average age of 37.8 years. The lesions, polypoid or granular, measured an average of 1.6 cm and involved the true vocal cords only (n = 4), false vocal cord only (n = 1), or were transglottic (n = 6). An acellular, amorphous, eosinophilic material was present in the stroma, often accentuated around vessels and seromucous glands, which reacted positively with Congo red. A sparse lymphoplasmacytic infiltrate was present in all cases that demonstrated light chain restriction by immunohistochemistry in three cases (kappa = 2, lambda = 1). Serum and urine electrophoreses were negative in all patients. Treatment was limited to surgical excision, including a single laryngectomy. Six patients manifested either recurrent and/or multifocal/systemic disease: two patients with light chain restriction were dead with recurrent disease (mean, 11.1 years); two patients were dead with no evidence of disease (mean, 31.7 years); and two patients were alive, one with light chain restriction and recurrent and multifocal disease (41.6 years) and one with no evidence of disease after a single recurrence (43.4 years). The remaining five patients were either alive or had died with no evidence of disease an average of 32.4 years after diagnosis. No patient developed multiple myeloma or an overt B-cell lymphoma. LA is an uncommon indolent lesion that may be associated with multifocal disease (local or systemic). The presence of an associated monoclonal lymphoplasmacytic infiltrate and recurrent/multifocal disease in the respiratory or gastrointestinal tract of a few cases and the lack of development of a systemic plasma cell dyscrasia or overt systemic B-cell malignancy suggest that some LA may be the result of an immunocyte dyscrasia or tumor of mucosa-associated lymphoid tissue.

Anesthetic management of a patient with laryngeal amyloidosis

A 73-year-old woman who suffered from progressive hoarseness for 6 years and dysphagia without pain for 1 year presented with a soft tissue deposition on the posterior region of the vocal cords and narrowing in the subglottic area. Biopsy of this soft tissue and histological examination revealed laryngeal amyloidosis. A tracheostomy and partial removal of the amyloid were performed with general anesthesia. The airway was secured with a smaller diameter endotracheal tube, which was inserted atraumatically with Magill's forceps. The larynx is a rare site for amyloidosis. Laryngeal amyloidosis is fragile and hemorrhagic. Therefore, massive bleeding may occur during intubation. Anesthetists should take care in intubating the tracheas of these patients and be aware of other systemic diseases in laryngeal amyloidosis.

Primary amyloidosis presenting as a nasopharyngeal mass

Amyloid is defined as a pathologic proteinaceous substance which, when deposited between the cells of tissues and organs, leads to various clinical conditions. Immunohistochemistry has allowed for better classification and understanding of the pathophysiology of amyloidosis. In the upper aerodigestive tract, amyloidosis is a rare condition occurring most frequently in the larynx. We present the case of a 42-year-old woman with complete nasal obstruction due to primary nasopharyngeal amyloidosis. This represents the first reported case of primary nasopharyngeal amyloidosis containing both the lambda and kappa immunoglobulin light chains. The clinical and radiologic findings, as well as the management of primary amyloidosis of the upper aerodigestive tract, will be discussed. A review of the literature pertaining to nasal and nasopharyngeal amyloidosis will be presented.

Localized amyloidosis of the parotid gland: a case report and review of the localized amyloidosis of the head and neck

BACKGROUND

Localized amyloidosis in the head and neck is a rare and benign process.

METHODS

We present the first case report in the literature of localized amyloidosis of the parotid glands and also comprehensively review the literature regarding localized amyloidosis of the head and neck.

RESULTS

Amyloidosis affecting the head and neck region is uncommon and is mostly in the form of localized amyloidosis. Larynx is the commonest site of involvement and accounts for 0.2% to 0.5% of benign laryngeal tumors. Laryngeal involvement could be either diffuse subepithelial deposition or discrete tumor nodules. Although localized amyloidosis occurs much more frequently in the oral cavity and pharynx, only seven cases of nasopharyngeal amyloidosis and eight cases of nasal septum amyloidosis have been reported. There is no documentation to suggest that localized amyloidosis can progress to systemic amyloidosis. Local surgical excision is the treatment of choice for laryngeal amyloidosis and laser excision is probably the best.

CONCLUSION

While localized amyloidosis of the head and neck region is rare, it should be recognized, understood, evaluated, and properly treated.

Upper airway obstruction in the rheumatic diseases

Upper airway obstruction is a potentially life-threatening event that can be managed effectively when promptly recognized and treated. For this reason, all patients who are suspected of having disease affecting the larynx or trachea should be regarded as having a potentially compromised airway until proven otherwise. Although clinically significant upper airway diseases occur infrequently in rheumatic disorders, these manifestations should be considered in such patients who present with upper airway symptomatology.

A HISTOLOGICAL STUDY OF HYALINE DEPOSITS IN LARYNGEAL, AURAL, AND NASAL POLYPS AND THEIR DIFFERENTIATION FROM AMYLOID

Sections of hyalinized laryngeal polyps stained with haematoxylin and eosin or Congo red can easily be confused with localized amyloid of the larynx. Several histological methods were applied to 61 specimens containing hyaline deposits or hyalinized tissues which included 36 laryngeal polyps. The results were compared with seven cases of localized amyloidosis of the upper respiratory tract and four cases of secondary amyloidosis. The hyaline deposits gave a pattern of results which were different from amyloid. They showed no metachromasia, low affinity for Congo red, weak birefringence in an unstained state, no birefringence if stained with Congo red, weak or negative fluorescence if stained with Thioflavin T, low resistance to pepsin digestion, positive phosphotungstic acid haematoxylin staining areas, and a high affinity for the picric acid component of van Gieson stain. Hyalinized collagen closely resembles amyloid, but it can be excluded by a van Gieson stain. No evidence of amyloid formation was found in areas of hyaline deposits in the larynx. This supports the view that localized amyloidosis of the larynx and hyalinized laryngeal polyps are different pathological entities.

Giant primary amyloidoma of the tonsil

A case of giant amyloidoma in the left tonsil with extensive osseous metaplasia and a scanty and patchy monoclonal population of IgG Kappa plasma cells, is presented. Localized tumoral amyloidosis is a rare, benign tumour of the upper aerodigestive tract. Organ-limited amyloidosis has been shown to be confined to various systems but, since the lesion was first described, only four cases situated in the tonsils have been reported in the English literature, and none of these had either osseous metaplasia or a monoclonal population of IgG Kappa plasma cells.

Amyloidosis of the larynx in a child

Localized laryngeal amyloidosis is a rare and benign process. Only three cases have been reported in children. We present the case of a 9-year-old girl with localized laryngeal amyloidosis that was excised via laryngofissure. The patient presented with a 3- to 4-week history of progressive hoarseness. Direct laryngoscopy revealed a smooth, firm, submucosal mass extending from the anterior aspect of the left false vocal cord to the vocal process. Biopsy of the mass revealed findings consistent with amyloidosis. The mass was approached via laryngofissure and excised with the thyroid cartilage and left true vocal cord left intact. An extensive workup for systemic amyloidosis was negative, including bone marrow biopsy. The postoperative recovery was uneventful, with good vocal quality and a sluggish but mobile left true vocal cord. This case is significant because of the young age of the child, the extent of disease, and the use of laryngofissure for excision.

Primary amyloidosis of the larynx

The history, examination and operative findings of primary amyloidosis of the larynx are very suggestive of carcinoma, indicating the need for careful histological examination. Staining with Congo red shows a characteristic birefringence. Systemic amyloidosis may be present.

Amyloidoma of the neck: case report and review of the literature

We present a case report of reactive amyloidoma of the neck in a patient with chronic calcaneal osteomyelitis. Localized deposits of amyloid may occur throughout the upper aerodigestive tract, but are rarely observed in the soft tissues of the neck. This is the first report in the literature of localized head and neck amyloidosis secondary to a chronic inflammatory or infectious process. A clinicopathologic review of amyloidosis is presented with particular attention to its head and neck manifestations.

Fatal massive upper respiratory tract haemorrhage: an unusual complication of localized amyloidosis of the larynx

Localized amyloidosis of the larynx is usually described as a non-bleeding lesion. We report a patient with localized laryngeal amyloidosis who developed a massive upper respiratory tract haemorrhage and died. This potentially fatal complication of localized amyloidosis of the larynx merits recognition as the disease could be controlled in most instances by surgical excision of the amyloid deposit.

Organ-limited laryngeal amyloid deposits: clinical, morphological, and immunohistochemical results of five cases

Five cases of organ-limited laryngeal amyloid deposits with no evidence of systemic disease are reported in detail and classified immunohistochemically. In four of the five cases the amyloid reacted with anti-A lambda antibodies and in one case with anti-A kappa antibodies. Four of our five female patients had already passed the fifth decade of life. One was 11 years old. Hoarseness was the predominant symptom in four cases, in which we found amyloid deposits in the glottic area. Only one patient, with amyloid deposits in the aryepiglottic fold, complained of pain. The therapy of choice of idiopathic, localized, or organ-limited amyloid deposits without underlying disease may be local excision. In one of the cases reported in this paper, a laryngofissure was performed, and in another a partial laser resection was performed. No therapy was performed in three of our five cases. In the larynx, as in many other locations and only if possible, removal at intervals is more feasible than radical resection, because these amyloid tumors grow slowly.

Laryngeal amyloidosis: a clinicopathologic and immunohistochemical review

The clinical nature of laryngeal amyloidosis has not been well established, and the natural history of the disease remains a controversial matter. To address these issues, we reviewed the clinicopathologic and immunohistochemical features of 22 cases (11 men and 11 women; mean age, 56 years) of laryngeal amyloidosis. Hoarseness was the most common symptom, and the most frequent site affected was the false vocal cords. Six patients had concomitant tracheal amyloidosis. Paraffin blocks were available for immunostaining in 20 cases. Nineteen cases were positive for amyloid P component. lambda-Light chains were detected in 12 cases and kappa-light chains in 5; three cases did not show definite light-chain staining. Ten patients underwent repeated operations for persistent or recurrent respiratory tract disease. One patient died of progressive tracheobronchial amyloidosis, but systemic amyloidosis did not develop in any of the patients. Laryngeal amyloidosis is a form of localized amyloidosis characterized by monoclonal light-chain deposition. Recurrent respiratory tract disease is not uncommon, but the usual clinical course is relatively benign.

Primary localized amyloidosis in one family

Primary localized amyloidosis was found in a family. A 66-year-old woman had suffered from hoarseness for 18 years. A biopsy specimen from the larynx showed amyloid deposits in the submucosal connective tissue. Her 40-year-old daughter noticed a subcutaneous nodule on her philtrum. Histologic examination showed the deposition of amyloid in the middle and lower dermis, which also encased the blood vessels and epidermal appendages. In both cases the amyloid deposits were positively stained with Congo red and the staining was resistant to potassium permanganate treatment. These amyloid deposits were strongly positive against the anti-amyloid antibody of the lambda light chain. These results indicate that the amyloid substance is derived from protein AL. There was no clinical or laboratory evidence of systemic amyloidosis or multiple myeloma in either patient.

Laryngeal amyloidosis in a child

A 14-year-old girl developed progressive hoarseness and breathing difficulty due to a mass in the subglottic larynx. A biopsy specimen obtained at direct laryngoscopy showed localized aggregates of amyloid. The lesion was excised completely with a carbon dioxide laser. This is the second case of laryngeal amyloidosis in a child reported in the English-language literature.

Immunoglobulin lambda-light-chain-derived amyloidosis (A lambda) in two horses

Tumorous amyloid deposits in the nasal mucosa of two horses differed from generalized AA-amyloidosis with respect to clinical features, organ distribution, and resistance to KMnO4 treatment. Using a panel of antibodies directed against different human amyloid fibril proteins and employing the peroxidase-anti-peroxidase (PAP) technique, we showed the described equine amyloid to be A lambda-type, as demonstrated by immunohistochemical cross-reactivity. Consequently, we identified a second amyloid class in horses and showed that immunoglobulin light-chain-derived amyloid may also be present in animals.

Light and electron microscopic studies of localized laryngeal amyloidosis

We performed light and electron microscopic studies in a case of localized supraglottic laryngeal amyloidosis involving a 55-year-old woman. Tissue specimens were stained with hematoxylin and eosin, and alkaline Congo red with or without permanganate (KMnO4) treatment, and were also examined with peroxidase-antiperoxidase immunohistochemistry. Biopsy specimens from the epiglottis showed diffuse replacement of the subepithelial region by amyloid, which showed a typical green birefringence under polarized light. Tissue affinity for Congo red was persistent after the KMnO4 treatment. However, the tissue sections showed a positive reaction only to the anti-P component antibody. Electron microscopic studies revealed some disorders of the plasma cells, suggesting that these cells play an important role in focal production of amyloid fibrils.

Clinical implications of laryngeal amyloidosis

Four cases of laryngeal amyloidosis are reported. For the present three of these cases have to be considered as primary localized amyloidosis, the type usually found in the larynx. Amyloid in the larynx may be a manifestation of the generalized or secondary form, which has to be excluded in each case. Diagnosis is provided by various histochemical stainings of which Congo red is the most specific one. Electron microscopy can be very helpful. Treatment consists of local excision. Recurrence may become manifest after several years and long-term follow-up is recommended.

Localized amyloidosis of the head and neck and upper aerodigestive and lower respiratory tracts

Seven cases of localized amyloidosis limited to structures of the head and neck and upper aerodigestive and lower respiratory tracts evaluated and treated at Boston University Hospitals in a recent 7-year period were reviewed. Negative Congo red staining of abdominal adipose aspiration biopsy or rectal biopsy specimens established that the amyloidosis was not systemic. Localized amyloidosis occurred in discrete masses in a variety of sites in the aerodigestive tract including the orbit, nasopharynx, lips, floor of mouth, tongue, larynx, and tracheobronchial tree. Five patients required surgical excision because of significant airway obstruction or organic dysfunction. Amyloid deposits completely excised with the carbon dioxide laser have not recurred, though other amyloid masses may appear elsewhere within the same organ or region. Amyloidosis may occur primarily or secondarily to other disease states. Localized amyloidosis has not been chemically identified but is usually defined by the absence of systemic features. While rare, amyloidosis must be recognized and understood by the otolaryngologist/head and neck surgeon to allow appropriate diagnostic and therapeutic planning.

Surgical treatment of the laryngotracheal amyloidosis

Two cases of primary localized amyloid tumor in the larynx and trachea surgically treated were herein reported. As recurrence of the amyloid tumor might lead to repeated resection in the same region, first trial of eradicative laryngofissure or laryngotracheofissure proved to be the effective approaches. The denuded area of the respiratory tract after removing amyloid tumor was covered with a split thickness skin graft and/or neighbouring mucosa applying soft rubber stent, then extensive scarring and schrinkage of the airways after surgery could thus be eliminated.

Laryngeal amyloidosis and laryngocele

Laryngeal amyloidosis and laryngoceles are uncommon. A unique case of both conditions occurring simultaneously is discussed. Preoperative computerized tomographic sections clearly demonstrated both disease processes, their extensiveness, and their intimate relation. These findings are correlated with the endoscopic and surgical findings. Gross and histopathologic specimens give full confirmation of the diagnosis. To our knowledge, this is the first case of laryngocele secondary to amyloidosis.