Acute fatal upper airway obstruction from an occult cavernous hemangioma of the larynx

Fatal asphyxia due to large laryngeal granuloma

Laryngeal granuloma, vocal process granuloma, or post-intubation granuloma are benign, inflammatory lesions of the arytenoid cartilage vocal process. The etiology of laryngeal granulomas is multifactorial, such as chronic irritation due to endotracheal intubation, vocal cord injury or trauma, and gastroesophageal reflux disease. They can arise postoperatively after mucosal injury due to orotracheal intubation. Clinical manifestations include voice change and dyspnea, which may start one to four months after extubation and may rarely lead to asphyxia. We presented a case of death due to glottic granuloma occurring after a surgical procedure to remove a laryngeal polyp attributed to previous laryngeal injuries by multiple intubations.

Vocal Cord Hemangioma: A Common Tumor in an Unusual Localization. A Case Report with Short Review of Literature

Laryngeal adult-type hemangiomas are very rare lesions, more frequent in men, whose optimal treatment consists of microlaryngoscopical excision. We herein report a case of larynx cavernous hemangioma in a 64-year-old woman with hoarseness for about six months. Histologically, the tumor was composed of multiple vessels embedded in an edematous stroma.

Spontaneous retropharyngeal haematoma: a rare cause of upper airway obstruction

Extensive retropharyngeal haemorrhage is a rare event, which is occasionally encountered in clinical practice, but very seldom at autopsy. A 43-year-old woman who presented with difficulty breathing after a week's history of sore throat and coughing is reported. She collapsed at a medical centre and was not able to be resuscitated. Staff noted that she had 'swelling' of her throat. At autopsy, the major findings were in the anterior neck where there was extensive and diffuse retropharyngeal haemorrhage extending throughout the soft tissue planes resulting in marked stenosis of the laryngeal inlet. There was no evidence of external or internal trauma, and although no specific source of the retropharyngeal haemorrhage was identified, the haemorrhage clearly originated from the retropharyngeal space with diffuse extension Her past medical history included anticoagulation for atrial fibrillation and heart valve replacements, hepatic steatosis and sleep apnoea. This case demonstrates a significant complication of oral anticoagulation therapy with underlying comorbidities which may result in significant neck haemorrhage with critical upper airway narrowing and rapid clinical deterioration.

Laryngeal oncocytic cystadenoma and sudden death

An 86-year-old woman with Alzheimer disease collapsed in her nursing home and was not able to be resuscitated. At autopsy, the major findings were in the larynx where a pedunculated oncocytic cystadenoma had occluded the glottis. Oncocytic cysts or cystadenomas of the larynx are rare histologically benign lesions that account for only 0.1-1% of laryngeal lesions. While the usual presentation is of a sensation of a mass in the throat, hoarseness, or stridor, very occasionally, there may be acute airway compromise and sudden death. Oncocytic cystadenoma should, therefore, be included in the differential diagnosis of potentially lethal obstructive laryngeal lesions.

Clinical Characteristics, Classification, and Management of Adult Nasopharyngolaryngeal Hemangioma

OBJECTIVES/HYPOTHESIS

To analyze the clinical features, classification, and treatment of adult nasopharyngolaryngeal hemangioma (ANPLH).

STUDY DESIGN

Retrospective study.

METHODS

From February 2009 to May 2020, 101 patients with ANPLH were reviewed and analyzed.

RESULTS

Symptoms of ANPLH were frequently displayed as abnormal pharyngeal sensation and functional defection. According to lesion location, ANPLH was divided into five categories including nasopharyngeal, oropharyngeal, hypopharyngeal, laryngeal, and mixed types. The mixed type constitutes the highest portion, and the nasopharyngeal type is the least in our cohort. Most lesions could resect through natural cavity under endoscopy. Patients with mixed lesions had a higher rate of postoperative recurrence and planned multiple surgeries. Acceptable but not severe intraoperative and postoperative complications occurred in our patient cohort.

CONCLUSIONS

Patients with ANPLH are always symptomatic and even functional defective, which can be classified into five categories based on lesion location. For these patients, endoscopic surgery through natural cavity is recommended to remove lesions with fewer complications and favorable clinical outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Ludwig angina and sudden death

A 27-year-old man presented to hospital with neck swelling and difficulty breathing following a recent tooth extraction. He underwent uncomplicated surgical drainage of the submandibular region after which he became acutely short of breath and collapsed and was not able to be resuscitated. At autopsy the major findings were swelling of the neck due to diffuse cellulitis with edema and neutrophil infiltrates within connective tissue and marked submucosal edema of the epiglottis, glottic inlet and tonsils sufficient to cause airway obstruction. Cultures from the site of surgical intervention showed a mixed growth of Gram positive and negative bacilli and Gram positive cocci. Death was due to airway obstruction resulting from marked submucosal edema of the glottic inlet associated with submandibular cellulitis (Ludwig's angina) following extraction of a right lower first molar tooth. Lethal Lugwig angina, although rare in current forensic practice, may still present as a cause of acute upper airway occlusion and must be considered in the differential diagnosis of significant upper airway compromise.

Adult cavernous haemangioma of the vocal cords with a unique presentation of acute respiratory distress: a case report

Laryngeal haemangiomas can commonly be seen in children, and first-line treatment is usually propranolol. However, in adults, cavernous haemangioma of the vocal cord(s) is an extremely rare condition - with this being the only published adult case presenting with acute respiratory distress - the mainstay of treatment is surgical excision under microlaryngoscopy. Presentation in adults can be unpredictable, but primarily consists of hoarseness which can be associated with, dyspnoea, dysphagia, and haemoptysis - and in one documented case stenosis of the aero-digestive tract led to death. Due to these airway difficulties, surgery can often prove challenging. In this study, we explore the unusual case of a previously well 71-year-old gentleman presenting to the Emergency Department, with worsening shortness of breath as his primary complaint. Uniquely, in this case, an awake fibre-optic intubation was undertaken to manage the difficult airway and a microlaryngoscopy was performed. A 20x10x15mm lesion was excised, which had characteristics in keeping with a cavernous haemangioma on microscopic examination.

Airway compromise and thyroglossal duct cysts in adulthood

A 61-year-old man died suddenly after a brief history of shortness of breath and hemoptysis. At autopsy he had lobar pneumonia involving the right upper and left lower lobes of the lung. Significantly there was also a 30 × 20 mm (in cross-section) thyroglossal duct cyst compressing the upper airway. Death was attributed to respiratory failure due to the combined effects of lobar pneumonia (cultures positive for Streptococcus pneumoniae) and airway narrowing from a thyroglossal duct cyst. Although such cysts are usually found in childhood they may on occasion be diagnosed in adults. Despite being the most common congenital cyst in the neck cases associated with a lethal outcome are extremely rare.

Delayed fatal upper-airway obstruction due to laryngopharyngeal burns and thermal epiglottis

A 48-year-old man complained of throat swelling and difficulty swallowing after eating hot food. Several hours later, he collapsed and was observed to be gasping for breath. Bystander and ambulance-initiated cardiopulmonary resuscitation was unsuccessful, and he was pronounced deceased at the scene. At autopsy, the aryepiglottic folds were markedly oedematous, with adjacent areas of mucosal inflammation and necrosis from a recent burn. Death was attributed to upper-airway obstruction due to glottic inlet oedema associated with epiglottic and laryngopharyngeal thermal injury. Although thermal epiglottitis not involving fire is an unusual injury and is rarely fatal, the reported case demonstrates a lethal episode arising from the ingestion of excessively hot food. Thermal epiglottitis therefore represents an uncommon cause of delayed upper-airway obstruction in adults that should be considered in individuals presenting with a sore throat and shortness of breath, particularly if there is a history of hot-food ingestion.

Laparoscopic instrument use in laryngeal surgery: transoral resection of a supraglottic haemangioma

BACKGROUND

Adult laryngeal haemangiomas are rare vascular tumours that have been managed by a variety of surgical techniques.

METHODS

This paper describes a case of near-fatal acute airway obstruction secondary to such a lesion, followed by our approach to surgical resection using a laparoscopic bipolar tissue-sealing device.

RESULTS

This technique resulted in successful excision of the lesion, with no evidence of recurrence at one year of follow up.

CONCLUSION

Laparoscopic bipolar instruments can be used for the resection of moderate to large laryngeal haemangiomas as an alternative to laser excision.

Vascular lesions simulating bruising

Careful examination of the skin and soft tissues is a routine part of the forensic autopsy to identify and characterise traumatic lesions. Three cases are reported where benign vascular lesions presented as bruises. In case 1, a 44-year-old man with a history of epilepsy was found dead on the floor. Dissection of the neck revealed a haemorrhagic area 15 mm × 1.5 mm, deep to the left thyrohyoid muscle. In case 2, an 87-year-old man was found dead with a plastic bag over his head attached to an opened cylinder of nitrogen gas. On the mucosal surface of his upper lip, there was an apparent 5 mm blue/purple bruise. In case 3, examination of the back of a 16-month-old girl revealed an apparent 15 mm bruise. Histological examination of all three lesions revealed benign vascular lesions. In the absence of microscopy, these lesions would have been considered traumatic in origin, raising the possibility of inflicted trauma.

The medico-legal observation of an aggressive urogenital fibromatosis with isolated development not related to any traumatic event

Desmoid tumor is a fibroproliferative neoplasm with an intermediate malignancy and it can be localized in every bodily district: some locations are considered exceptional, like the urogenital localization. The Author point out a rare case of giant idiopathic scrotal fibromatosis that was found during an autopsy. A widower, that lived alone in poor hygienic conditions, was found dead in his house. The Judicial Authority ordered the autopsy, that was performed two days later at the Medico-Legal Section of Milan University. External examinations revealed only the considerable dimension of the scrotum (cm 24 × 41). The cause of death was fixed in a cardiac tamponade due to a natural heart laceration localized in correspondence of a transmural infarction. The toxicological exam resulted negative, while the histopathological and immunohistochemical analysis qualify the scrotal mass as a desmoids tumor. Due to the absence of predisposing conditions and of fibroproliferative infiltration in bladder and retroperitoneal space, the neoplasm was configured as an idiopathic desmoid tumor. The presented case gives the reason for the discussion concerning medico-legal aspects that are typical of rare neoplasms.