MR imaging of squamous cell carcinoma of the larynx and hypopharynx

Despite recent diagnostic advances, the laryngopharynx remains an area where accurate assessment of tumor size and extent is difficult. Computed tomography has proven helpful in delineating lesions in these areas, yet significant limitations exist. In an attempt to more accurately evaluate laryngopharyngeal neoplasms, MR imaging was performed in 25 consecutive patients with squamous cell carcinoma of the larynx and hypopharynx. Mr imaging was analyzed for its utility in clinical staging, assistance in selection of candidates for conservation, Laryngeal surgery, and ability to reliably predict cartilage invasion. MR imaging improved the accuracy of tumor staging by 40% and was valuable in the selection of candidates for conservation surgery. In addition, MR imaging was able to predict cartilage invasion in 6 of 6 patients with pathologic confirmation with a single false-positive case. MR imaging appears to be a reliable indicator of tumor size and location and should be judiciously incorporated into the staging and pretreatment planning of patients presenting with laryngopharyngeal malignancies.

Laryngeal changes during exercise and exercise-induced asthma

Exercise-induced asthma is defined as bronchospasm within the distal airways initiated by exercise. Whether the larynx responds to produce an exacerbation or alleviation of symptoms during an attack has never been evaluated. Thirty subjects were tested, including 15 normals and 15 with exercise-induced asthma. Laryngeal response to exercise was determined by measuring the area of the glottic aperture before, during, and after exercise. The glottis was visualized with a flexible laryngoscope and video images were recorded during monitoring of respirations. Asthma was induced in subjects by having them exercise on an ergometer for 10 minutes while breathing dry air at 10 degrees C. Measurements were subsequently made from recorded images and relative glottic areas were compared between groups. Our data quantify the normal physiologic response of the larynx to exercise and demonstrate a substantial laryngeal contribution to asthma induced by exercise.

Platysma myocutaneous flap for repair of hypopharyngeal strictures

Hypopharyngeal strictures, either isolated or in conjunction with laryngeal and esophageal strictures, can occur following lye ingestion. Extensive stricture formation requires reconstruction to create a functional funnel system that empties below the cricoid. Esophageal replacement is not a substitute for adequate hypopharyngeal reconstruction. The pectoralis major muscle is often inadequate, because it yields too much bulk and often leads to continued aspiration. The platysma myocutaneous flap for hypopharyngeal reconstruction has not been previously reported. The inferiorly based platysma myocutaneous flap was used in two of our patients with lye burns, and bilateral superiorly based flaps were used in one. All are able to eat normally and have no significant stenosis. The platysma myocutaneous flap is a relatively simple and reliable alternative that is within the capability of every head and neck surgeon.

Chondrosarcoma of the larynx. Diagnosis with magnetic resonance imaging and computed tomography

Chondrosarcomas are the most common sarcomas of the larynx. They are generally slow-growing lesions with insidious onset of symptoms. We are presenting a case of chondrosarcoma that recurred 10 years after excision of a presumed chondroma. Computed tomographic and magnetic resonance imaging (MRI) scans were performed. Both studies delineated the lesion nicely. To the best of our knowledge, this is the first report on MRI characteristics of chondrosarcoma of the larynx. A review of the literature regarding the use of computed tomography in the management of chondrosarcoma is presented. The MRI characteristics are discussed and the two scanning modalities are compared. Computed tomography is an excellent study in its ability to demonstrate the extent of the lesion within the laryngeal skeleton. Furthermore, it is more highly sensitive than plain roentgenograms in the detection of calcifications that are highly suggestive of chondrosarcoma. Alternatively, MRI can also demonstrate the lesion within the larynx but it has the added advantage of superior contrast resolution of the tumor and paralaryngeal tissues. When the three-dimensional imaging capacity of MRI is considered as well, MRI seems to be the superior study.

Epiglottic laryngoplasty for repair of blunt laryngopharyngeal trauma

Two unique cases of blunt laryngopharyngeal trauma are presented in which identical injuries were sustained to the supraglottic larynx and hypopharynx. Examination of the patients included the use of magnetic resonance imaging to help define the extent of injury. A successful outcome was achieved in each instance by employing the reconstructive technique of epiglottic laryngoplasty to repair the mucosal defects.

Successful use of nasal-CPAP for obstructive sleep apnea in Hunter syndrome with diffuse airway involvement

A patient with Hunter syndrome and diffuse airway obstruction had daytime hypersomnolence, snoring, and alveolar hypoventilation. Polysomnography showed severe obstructive sleep apnea. In the past, all reported cases of sleep apnea in patients with mucopolysaccharidoses had been treated with tonsillectomy/adenoidectomy or tracheostomy. This patient, in whom tracheostomy would have been very difficult due to the diffuse nature of his airway involvement, was successfully treated with high pressure nasal CPAP and supplemental oxygen.

Evaluation and treatment of acute laryngeal fractures

Treatment of laryngeal fractures continues to evolve, and the airway now can be restored without stenosis or aspiration in most cases. However, the best treatment of vocal cord dysfunction from trauma remains uncertain, and the value of computerized tomographic scan (CT) is controversial. In this report, we describe the symptoms, radiologic findings, and treatment of 15 consecutive cases of laryngeal trauma. The value of CT for assessing the cricoarytenoid area is discussed. We also found CT to be reliable for defining the extent of soft tissue trauma and for diagnosing the presence and displacement of any fractures. Endoscopic photographs are compared with CT scan photographs to illustrate the correlation of CT with the degree of trauma. Finally, we present a method of laryngeal fracture repair using autologous thyroid cartilage.

Ventral cleft of the larynx in an adult. Case report

Congenital clefts of the larynx are rare and usually found dorsally. This case report describes a patient with a partial anterior nonfunsion, or ventral cleft, of the thyroid cartilage. This was first noted on computed tomography of the larynx used for delineation of carcinoma and was confirmed by horizontal whole mount histologic sections of the resected larynx. The thyroid cartilage suggested arrested fusion of the laminae in the middle to late embryonic period. This patient had an adult form of this rarely reported anomaly and the first, to our knowledge, detected with CT scan.

Evaluation of laryngeal calcium deposition: a new methodology

Despite study for over 100 years, sites and patterns of laryngeal calcification and ossification are understood incompletely. Methodologies used in the past have included radiographic imaging and histologic staining with hematoxylin and eosin. Investigation of this subject offers potential application in the correlation of laryngeal disease with loss of normal calcification patterns. A technique for the detection of calcium deposition in human larynges, formerly used only in staining bony and cartilaginous tissue of small vertebrates, is described. This technique offers the advantage of whole organ staining and provides a sensitive means of determining degree and pattern of laryngeal calcification. The results of our pilot investigation with photographic examples are presented.

Lathyrogenic agents as therapy for subglottic stenosis--a pilot study

The surgical repair of subglottic stenosis (SGS) is often unsuccessful because of recurrence of the scar contracture. Over the past few years, two lathyrogenic agents (compounds that inhibit collagen cross-linking) have been shown effective in prevention of stenosis in animal models that have deep caustic esophageal burns. Since the principles of induced lathyrism have not been applied to the treatment of laryngotracheal stenosis, a pilot study using a canine model was conducted to test the efficacy of penicillamine and N-acetyl-L-cysteine in reduction of the rate of reformation of SGS. In all six animals used, a complete, 10 to 15 mm thick, mature SGS was induced experimentally, then opened with a CO2 laser. The dogs that were treated with lathyrogenic agents exhibited a lower rate of re-stenosis (one maintained patency throughout the 5 weeks of treatment) when compared to the two control dogs. Histologic sections of the subglottis in each dog revealed severe cricoid collapse, necrosis, and scarring, and thus demonstrated similarities to SGS in human beings. The two lathyrogenic agents used in this study are already approved for human use and may represent a valuable form of adjunctive therapy in the surgical management of SGS.

Caustic ingestion in adult patients

Sixteen adult patients who ingested caustic substances were seen from 1977 through 1984. All patients underwent endoscopy to determine the site and severity of burns; mild hyperemia to severe, penetrating necrosis was detected in each patient. Ten ingestions were intentional, 4 accidental, and 2 questionably accidental. Morbidity and mortality were high, especially in patients who ingested caustic materials intentionally. A protocol for treatment with steroids and antibiotics was followed in half the patients studied. Those patients who completed this regime tended to have moderately severe burns. Caustic ingestion in adults must be viewed as a problem different from that of accidental ingestion in children. Since most adult caustic ingestions are intentional, the injuries are worse, more deaths result, and more severe scars causing permanent disability are a frequent outcome.

Dysphagia and Forestier's disease

Dysphagia is a common complaint of patients seen by otolaryngologists. Cervical osteophytes have been widely reported as a cause of dysphagia. Recently, Forestier's disease (vertebral ankylosing hyperostosis or diffuse idiopathic skeletal hyperostosis) has also been identified as a cause of dysphagia. Two patients had dysphagia due to Forestier's disease. Their barium esophagograms demonstrated narrowing of the esophagus due to the vertebral osteophytes and their computed tomographic scans show the extent of the osteophyte deformity.

Relationship of laryngeal dimensions to body size and gestational age in premature neonates and small infants

The larynges of 27 infants weighing between 250 gm and 9160 gm were studied. Twenty-two neonates were from 24 to 40 weeks' gestational age. Five subjects died more than 6 weeks post partum but were included because of their small size. Relationships of larynx size to the standard clinical measurements of crown-heel length, crown-rump length, head circumference, and gestational age were developed. Cartilage size relationships to these measurements were found to be linear. Glottic length related linearly to crown-rump length but related in a curvilinear way to crown-heel length, head circumference, and gestational age. A guide to the choice of endotracheal tube sizes for small infants is suggested.

Cartilage involvement in laryngeal carcinoma: correlation of CT and pathologic macrosection studies

Fifteen patients with laryngeal epidermoid carcinoma underwent CT of the larynx prior to surgery. Whole mount sections of the extirpated larynx cut in the horizontal plane were compared with the corresponding level of the preoperative CT sections. This study in particular was designed to evaluate the accuracy of diagnosing cartilage involvement by CT and to correlate CT findings with histologic involvement. Our results indicate that CT correlates well with anatomic location of gross cartilage involvement by the tumor; however, small macroscopic invasion of the laryngeal cartilages may be difficult to diagnose with CT. Microscopic involvement of the cartilages cannot be diagnosed with CT. Decisions regarding conservation surgery cannot be based on CT evaluation alone.

Wildervanck syndrome--the external appearance and radiologic findings

Wildervanck syndrome is a combination of congenital anomalies characterized by deafness, Klippel-Feil deformity, and an unusual ocular motility disturbance called Duane retraction syndrome. This syndrome is seen infrequently in the general population and may not be recognized since the external appearance of the ears may be normal, and the unusual form of strabismus may not be obvious to the non-ophthalmologist. Patients with the full extent of this triad have a unique appearance. CT examination in these patients delineates the cervical anomalies as well as the inner ear deformity.

Radiographic features of the ear-related developmental anomalies in patients with mandibulofacial dysostosis

Among the conditions that arise from disturbances in development of the first two branchial arches, the symmetric syndrome of mandibulofacial dysostosis and the asymmetric anomalies of the hemicraniofacial microsomia represent a characteristic pattern of craniofacial malformation distinct from other first and second arch syndromes. Since the usual embryonic aberration in both of these anomalies involves the first and second branchial arch derivatives, malformations of the external and middle ear are common. The external auditory canal is absent in the vast majority of the cases. Incudomallear deformities are usually present. In this paper, radiographic analysis of the ear-related developmental anomalies of 17 patients with mandibulofacial dysostosis is described.

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.

Computed tomography of the larynx: correlation with anatomic and pathologic studies in cases of laryngeal carcinoma

Seven patients with known carcinoma of the larynx underwent computed tomography (CT) of the larynx prior to surgery. Whole-mount sections of the extirpated larynx cut in the horizontal plane were compared with the corresponding level of the preoperative CT sections to demonstrate the validity of CT scanning in the evaluation of tumors of the larynx. The results indicate that CT scanning accurately demonstrates the anatomic location and gross size of laryngeal tumor, although early invasion of the laryngeal cartilages may be difficult to diagnose with CT. It is concluded that preoperative CT scanning of the larynx is the radiologic procedure of choice for evaluating carcinoma of the larynx.

Laryngeal malignancies and computerized tomography. A correlation of tomographic and histopathologic findings

We compared the anatomic structures, computerized tomographic (CT) scan images and the histopathologic findings after surgery in 15 patients with laryngeal epidermoid carcinoma. We examined the horizontal whole-mount histologic sections along with the preoperative CT and verified the preoperative impression of the soft tissue changes of preepiglottic space involvement; true cord, false cord and aryepiglottic fold invasion; or subglottic extension in all 15 patients. It was impossible to judge reliably the microscopic invasion of bone or cartilage with this method. Preoperative CT evaluation of carcinoma of the larynx was a reliable method for judging gross tumor size, though decisions regarding conservation surgery cannot be based on CT evaluation alone.

Peroral endoscopy in neonates

A study was made of 100 neonates examined by 171 procedures in a 5 year period. Thirty-six patients had vocal cord palsies: unilateral, bilateral, complete or incomplete. Twenty-four infants had laryngomalacia of which 5 had concomitant problems of multiple congenital anomalies or palsies of varying severity. Laryngeal stenosis was encountered in 13 patients. Four of these were congenital, and two required tracheotomy; 8 of the 9 patients with acquired stenosis required tracheotomy. Nine infants had cardiovascular anomalies. Three were seen following TEF repair. Esophageal foreign bodies (endotracheal tube) were removed from two infants. Of the 28 neonates who had tracheotomies, 13 had vocal cord palsies, 10 had laryngeal stenosis and 8 had congenital cardiovascular disease. In the 171 procedures, anesthesia was used 18 times for tracheotomy and 7 times for repeated procedures. There were 3 deaths in this series, all related to the underlying disease. This study indicates that endoscopic examinations of the neonate can be accomplished safely. It further indicates the diverse diseases for which endoscopy is indicated. General anesthesia is not mandatory for such examinations.

Lymphoid hyperplasia of larynx simulating neoplasia

A rare case of lymphoid hyperplasia of the adult larynx (hyperplasia of the laryngeal tonsil) is reported. While this benign lesion recurred following surgical excision, the patient has been followed for more than two years without additional therapy and is asymptomatic. Seven additional cases of laryngeal lymphoid hyperplasia in the English literature are reviewed. The problems related to inadequate sampling (biopsy) and the histologic criteria for diagnosis are emphasized. To define the pathogenesis and ultimate biologic potential of this lesion, more cases must accrue and be studied with a long follow-up.

Subglottic stenosis in infants and children

Of 158 cases of subglottic stenosis 115 were congenital and 43 acquired. Current follow-up has been obtained in 146 (92%) which constitutes the determinate group. Although stridor was the most common presenting symptom of the congenital group, 34% presented with recurrent or prolonged episodes of croup. Tracheotomy was required in 47 of the 107 determinate cases (44%). Further management of the congenital cases was based on the experience that children outgrow this disorder; periodic dilatation may augment the natural process. Of those infants and children tracheotomized, all but five have been decannulated, and there was one death - a mortality rate of 2.1%. Acquired subglottic stenosis proved to be a more difficult management problem. Tracheotomy was necessary in 38 of the 39 determinate cases (97%). Repeated active dilatations for prolonged periods were usually required as well as endoscopic removal of granulation tissue. Of those infants and children tracheotomized, all but eight have been decannulated. There were nine deaths; five were due to unrelated underlying disease; four were attributable to complications of long-term tracheostomy. Thus, in the entire series, 85 infants and children required tracheotomy and five deaths may be attributable to long-term tracheostomy complications - a mortality rate of 5.9%.

Tracheostomy in the first year of life

Three series totaling 301 infants under 1 year of age who had tracheotomies during three successive decades are reviewed. The first series (62 infants) was seen prior to 1953, the second (86 infants) was seen between 1954 and 1963, while the latest series (153 infants) was seen between 1964 and 1973. A comparison of the three series with reference to etiology, incidence, indications, management, and mortality leads to significant conclusions. (1) The incidence of tracheotomy is increasing. More aggressive approach to many problems, previously considered inoperable, resulted in an increased number of infants undergoing tracheotomy for postintubation problems and ventilatory support. (2) The incidence of congenital malformations of the airway necessitating tracheostomy has remained constant, while the downward trend in the incidence of inflammatory conditions was reversed. (3) Infants in the latest series underwent tracheotomy, on the average, at a later age than the 1954 to 1963 series, largely as a result of the increased number of patients with cardiac anomalies undergoing corrective cardiovascular surgery and subsequent tracheotomy at a later age. (4) A review of the 77 deaths in the latest series again shows the death rate to be dependent on the underlying systemic condition which necessitated tracheotomy, rather than the tracheostomy itself. (5) The importance of temporary intubation to relieve respiratory obstruction in infants is stressed, while the significant laryngeal damage following prolonged intubation and delayed tracheotomy is apparent.

Extraluminal foreign bodies (coins) in the food and air passages

Four children with foreign bodies found outside the lumen of the upper food and air passages are presented. The diagnostic difficulty of such extraluminal foreign bodies and the importance of accurate localization by endoscopy and radiologic examination prior to external surgical removal are discussed.

Delayed C.N.S. complications

Patients with esophageal stricture being treated with dilatation, who developed esophageal perforation or local peritonitis and subsequent central nervous system infection, are reviewed. It is suggested that the vertebral venous system may be the route by which the metastatic infection is carried. Physicians caring for patients with esophageal stricture, who are receiving dilatation, should be aware of the possible intracranial complications and should be alert to the first sign of central nervous system abnormality.