Clinical implications of laryngeal amyloidosis

Airway Amyloidosis: A Retrospective Analysis of 43 Patients

BACKGROUND

Amyloidosis can involve any compartment in the thorax. We aimed to explore the clinical and radiologic presentation, treatment, and clinical course of airway amyloidosis.

METHODS

A computer-assisted search was performed to identify patients who had biopsy-proven airway amyloidosis and were evaluated at Mayo Clinic in Rochester, MN, from January 1, 1997 through December 31, 2019. Demographic, clinical, and radiologic features along with clinical outcomes were analyzed.

RESULTS

We identified 43 patients who had airway amyloidosis. Median age was 60 years (range: 33 to 91 y), and 58% were female. Shortness of breath (63% of patients) and cough (44%) were the most common presenting symptoms. Most patients (82%) had localized amyloidosis with light chain being the most common amyloid type; 63% had tracheobronchial amyloidosis, and 23% had tracheal and upper airway involvement. On computed tomography of the chest, the most common findings were airway wall thickening with nodularity (60% of patients), airway calcification (53%), and airway occlusion without collapse (47%). On bronchoscopy (33 patients), the extent of amyloid involvement was most commonly submucosal (n=15) or nodular (n=8). External beam radiotherapy was the most common treatment modality. Among the 30 patients who had follow-up at our institution, the prognosis appeared to depend on the extent of the disease and whether patients had localized or systemic amyloidosis.

CONCLUSION

Computed tomography of the chest, bronchoscopy, and biopsy are needed to establish the diagnosis of airway amyloidosis, and systemic amyloidosis should be ruled out. Treatment of amyloidosis requires a multidisciplinary approach.

Localised laryngotracheal amyloidosis: a differential diagnosis not to forget

We present a case of multifocal laryngotracheal amyloidosis (LTA) in a 43-year-old man with persistent and progressive dysphonia and dyspnoea, and a first inconclusive histology. Although laryngeal amyloidosis accounts for fewer than 1% of all benign laryngeal tumours, it is in fact the most common site of amyloid deposition in the head, neck and respiratory tract. The clinical scenario is non-specific and diagnosis depends on a high degree of suspicion and on histology. Imaging is useful in mapping lesions, which are often more extensive than they appear during laryngoscopy. Despite being a benign entity, the prognosis is variable with a high-rate and long-latency recurrences, requiring long-term follow-up.

Risk factors for recurrence of laryngeal amyloidosis treated by microforceps and CO2 laser

INTRODUCTION

Laryngeal amyloidosis is a benign, slowly progressive disease. The factors affecting the recurrence of LA have not been studied before for the rarity and incomplete understanding of this disease. To investigate the risk factors for the laryngeal amyloidosis treated by microforceps or carbon dioxide laser under microlaryngoscope, a retrospective review was conducted.

MATERIALS AND METHODS

One hundred and four patients (42 male and 72 female, with an average age of 51.3 years) with laryngeal amyloidosis were identified. The cases were collected from January 1989 to May 2014 at the Eye, Ear, Nose, and Throat Hospital of Fudan University.

RESULTS

Seventy-five patients complained of hoarseness, 36 patients complained of hoarseness and dyspnea, and 3 patients complained of foreign body sensation. All patients underwent surgical removal of the amyloid deposits (via microforceps, CO₂ laser and tracheotomy). Thirty patients developed recurrences requiring further treatments. The duration from onset to the treatment and age affected the recurrence of laryngeal amyloidosis, the surgery method, stenotic degree and stenotic area of subglottic area and trachea did not affect the recurrence of the disease.

CONCLUSION

Early diagnosis and treatment of laryngeal amyloidosis may reduce the recurrence of the disease. Regular follow-up is necessary to find any recurrence.

Laryngeal amyloidosis: diagnosis, pathophysiology and management

Background:

Laryngeal amyloidosis represents approximately 1 per cent of all benign laryngeal lesions, and can cause variable symptoms depending on anatomical location and size. Treatment ranges from observation through to endoscopic microsurgery, laser excision and laryngectomy.

Objectives:

To highlight the diversity of presentations, increase awareness of paediatric amyloidosis and update the reader on current management.

Case series:

Five cases are illustrated. Four adult patients were female, and the one child, the second youngest in the literature, was male. Amyloid deposits were identified in all laryngeal areas, including the supraglottis, glottis and subglottis. Treatment consisted of balloon dilatation, endoscopic excision, laser cruciate incision, and resection with carbon dioxide laser, a microdebrider and coblation wands.

Conclusion:

Laryngeal amyloidosis remains a rare and clinically challenging condition. Diagnosis should be considered for unusual appearing submucosal laryngeal lesions. Treatment of this disease needs to be evaluated on a case-by-case basis and managed within an appropriate multidisciplinary team.

KTP Laser in Laryngeal Amyloidosis: Five Cases with Review of Literature

To study the clinical presentation and review the options in the management of laryngeal amyloidosis. To study the efficacy of KTP 532 laser in the excision of laryngeal amyloidosis. Study was conducted in our department in a tertiary care hospital between Jan 2001 and Feb 2010. We report five patients who presented with hoarseness of voice and localized laryngeal lesions. The biopsy proven laryngeal amyloidosis lesions were excised microendoscopically using KTP 532 laser in three patients and other two patients were kept only on follow-up as they refused further surgery. The patients were evaluated for systemic amyloidosis. The average duration of follow up was 2.6 years (3 months 6 years). All the five patients in our study were asymptomatic with no evidence of recurrence at their last follow up. In our small case series, KTP 532 laser excision of the laryngeal amyloidosis had a favorable outcome. Long term follow up is required to rule out recurrence and systemic involvement.

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.

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.

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.

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.

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.

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 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.

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.