Auricular and laryngeal chondritis in nursery and finishing pigs

This work aimed to characterize the clinic-pathological presentation of an outbreak of auricular and laryngeal chondritis in pigs. Visits were made to pig farms, where the clinical history was obtained, and clinical and postmortem examinations were performed. In those farms, 3% to 4% of pigs presented otohematomas, which started in the nursery and extended to the finishing phase. Moreover, some finishing pigs presented with respiratory distress, initially characterized as inspiratory dyspnea, associated by an uncommon respiratory stridor and culminating in death. Grossly, nursery piglets had enlarged ears, and on the cut surface, the cartilage was fragmented and associated with blood clots. In the finishing phase, in addition to auricular lesions, the epiglottis and arytenoid cartilages were thickened and distorted, which partially occluded the lumen. Microscopically, the laryngeal and auricular cartilages were fragmented, displayed a loss of matrix basophilia, and were surrounded by lymphohistiocytic inflammatory infiltrate, with occasional multinucleated giant cells and fibrosis. The lesions exclusively affected elastic cartilages. The disease in finishing pigs led to increased mortality and was a differential diagnosis to respiratory challenges. It was not possible to determine the factor that triggered this condition; however, a nutritional association is suspected. To the authors' knowledge, this is the first report of primary auricular and laryngeal chondritis in pigs.

Radiological correlates of vocal fold bowing as markers of Parkinson's disease progression: A cross-sectional study utilizing dynamic laryngeal CT

OBJECTIVE

To determine whether arytenoid cartilage position and dynamics change with advancing duration and severity (as graded by MDS-UPDRS part III scores) in Parkinson's disease, in a cross-sectional study design, we performed laryngeal four-dimensional computed tomography (4D-CT) in people with Parkinson's disease and controls.

METHODS

31 people with Parkinson's disease covering a range of disease duration and severity and 19 controls underwent laryngeal 4D-CT whilst repeatedly vocalizing. We measured on each CT volume the glottic area (GA), inter-arytenoid distance (IAD), IAD-Area index (IAI) and arytenoid cartilage velocity ([Formula: see text]).

RESULTS

People with Parkinson's disease had reductions in the mean/effective minimum IAD when compared to controls, while mean/effective minimum GA and mean/effective maximum IAI were increased. Arytenoid cartilage velocities showed no difference. On Spearman correlation analyses, advancing disease duration and severity of PD showed moderately strong and significant correlations with increasing mean/effective minimum GA, increasing mean/effective maximum IAI and decreasing effective minimum IAD. Linear mixed models which considered the effects of intra and inter-individual variation showed that both disease duration (b = -0.011, SEb = 0.053, 95% CI [-0.022, 0], t(27) = -2.10, p = 0.045) and severity (b = -0.069, SEb = 0.032, 95% CI [-0.14,-0.0039], t(27) = -2.17, p = 0.039) were significant predictors for IAD, and also for transformed values of the GA and IAI.

CONCLUSIONS

There are progressive alterations in phonatory posturing as Parkinson's disease advances. The increases in GA despite reductions in IAD are concordant with prior observations of vocal fold bowing. Our study provides a basis for using laryngeal 4D-CT to assess disease progression in Parkinson's disease.

Cricoarytenoid joint arthritis: a possible complication of dermatomyositis

Cricoarytenoid joint arthritis is most frequently reported in Rheumatoid Arthritis and in other systemic diseases such as Sjogren's syndrome, Systemic Lupus Erythematosus, Ankylosing Arthritis, Juvenile Chronic Arthritis, and autoimmune hepatitis but it has not been reported in dermatomyositis. In this paper, we report the case of a 43 years-old woman treated for dermatomyositis who presented with hoarseness and severe odynophagia. The laryngoscopy revealed the presence of an extensive white swelling of the left cricoarytenoid joint with reduced mobility of the left vocal cord, consistent with left cricoarytenoid joint arthritis, which has not previously been described in dermatomyositis to our knowledge. Treatment with high doses of prednisone produced a complete resolution of the laryngeal symptoms.

A RAPGEF6 variant constitutes a major risk factor for laryngeal paralysis in dogs

Laryngeal paralysis (LP) is the inability to abduct the arytenoid cartilages during inspiration, resulting in a partial to complete airway obstruction and consequent respiratory distress. Different forms of LP with varying age of onset exist in dogs. Hereditary early onset forms were reported in several dog breeds. In most breeds, hereditary LP is associated with other neurologic pathologies. Using a genome-wide association study and haplotype analyses, we mapped a major genetic risk factor for an early onset LP in Miniature Bull Terriers to a ~1.3 Mb interval on chromosome 11. Whole genome sequencing of an affected Miniature Bull Terrier and comparison to 598 control genomes revealed a 36 bp insertion into exon 15 of the RAPGEF6 gene (c.1793_1794ins36). The imperfect genotype-phenotype correlation suggested a complex mode of inheritance with a major genetic risk factor involving a recessive risk allele. Homozygosity for the insertion was associated with a 10- to 17-fold increased risk for LP. The insertion allele was only found in Miniature Bull Terriers and Bull Terriers. It was absent from >1000 control dogs of other dog breeds. The insertion sequence contains a splice acceptor motif leading to aberrant splicing in transcripts originating from the mutant allele (r.1732_1780del). This leads to a frameshift and a premature stop codon, p.(Ile587ProfsTer5), removing 64% of the open reading frame. Our results suggest an important role of RAPGEF6 in laryngeal nerve function and provide new clues to its physiological significance.

Laryngeal paralysis (LP) leads to respiratory distress in affected dogs and can be fatal in severe cases. Many different forms of LP with different etiologies exist. Striking breed predispositions suggest that genetic factors contribute to some forms of LP. During the last years, dog breeders noticed an increased prevalence of an early onset LP in Miniature Bull Terriers. We mapped a major risk locus for this specific form of LP to a ~1.3 Mb interval on dog chromosome 11. Whole genome sequence analysis of an affected dog and comparison to 598 control genomes revealed a single protein-changing genetic variant in the critical interval. This variant, a 36 bp insertion into a coding exon of the RAPGEF6 gene, creates a cryptic splice site and leads to the expression of an aberrantly spliced transcript with a premature stop codon. This suggests that the insertion results in a loss-of-function allele. Dogs that are homozygous for the insertion have a 10- to 17-fold increased risk to develop LP. The genotype-phenotype association is not perfect, suggesting that other genetic and/or environmental factors also contribute to the development of LP. Our results suggest an important role of RAPGEF6 in laryngeal nerve function.

Age-related changes affecting the cricoarytenoid joint seen on computed tomography

We conducted a retrospective chart review to compare four characteristics-cricoarytenoid joint ankylosis, narrowing, erosion, and density increases-in patients younger and older than 65 years. Our study population was made up of 100 patients, who were divided into two groups on the basis of age. The younger group (<65 yr) comprised 49 patients (27 men and 22 women), and the older group (≥65 yr) was made up of 51 patients (25 men and 26 women). Findings on computed tomography (CT) of the neck were used to determine whether each of the four characteristics was present or absent. Overall, we found only one statistically significant difference between the two groups: ankylosis was significantly more common in the older group (p = 0.036). When we looked further at the side of these anatomic changes, we found that the older group had significantly more right-sided and left-sided ankylosis than did the younger group (p = 0.026 for both), as well as significantly more left-sided narrowing (p = 0.028) (some patients had bilateral involvement). When we analyzed age as a continuous variable, older age was again associated with significantly more ankylosis (p = 0.047) and narrowing (p = 0.011). We conclude that CT can be useful for assessing radiologic changes in the cricoarytenoid joint in elderly patients during the workup of dysphonia and abnormal movement of the vocal folds.

A clinico-pathological study of laryngeal and hypopharyngeal carcinoma: Correlation of cord-arytenoid mobility with histopathologic involvement

Objective

This study evaluates the vocal cord and arytenoid mobility in relation to the tumoral involvement of the cricoarytenoid joint (CAJ), thyroarytenoid (TA) muscle, and posterior cricoarytenoid (PCA) muscle in whole-organ sections of total laryngectomy specimens.

Study Design and Setting

The study was prospectively carried out between 1998 and 2003 and involved 133 primary squamous cell carcinoma cases of larynx or pyriform sinus that were treated with total laryngectomy. Preoperative mobility of vocal cords and arytenoids were evaluated seperately and correlated with histopathologic findings.

Results

In cases with fixed vocal cord CAJ, TA muscle, and PCA muscle were involved in 42.4%, 72.9%, and 27.1% of the cases, respectively, while in cases with fixed arytenoid these structures were affected in 40%, 66.3%, and 25.3% of the cases. Weight effect seemed to play a role in 60% and 50% of the cases of supraglottic and pyriform sinus carcinoma, respectively.

Conclusion

Careful evaluation of the mobility of the cord arytenoid unit separately helps the surgeon to better understand the patterns of tumoral extension guiding for the appropriate surgery which should be undertaken.

[Diagnosis and treatment of vocal process granuloma induced by gastroesophageal reflux: four cases report]

OBJECTIVE

To explore the mechanism, clinical characterization, diagnosis and therapeutic approach of vocal process granuloma(VPG) induced by gastroesophageal reflux.

METHOD

We performed a retrospective review of 4 cases.

RESULT

In 4 male cases, 3 cases had no obvious symptoms of stomach and esophagus and 1 case had symptoms of bloating and acid reflux. Additionally, 4 cases in which lesions were all located to the left side were diagnosed by trial therapy with proton pump inhibitors (PPIs) with good responding. 2 of 4 cases were relapsed after operations. Meanwhile 4 patients were treated by Rabeprazole for acid suppression therapy and 3 cases were cured and 1 invalid case was cured by Pantoprazole. All patients were followed up for 4-48 months with no recurrence.

CONCLUSION

Gastroesophageal reflux is an important pathogenic factor to the VPG. The majority of patients with VPG do not have gastroesophageal reflux symptoms. Besides, most lesions located in the left are associated with sleeping position. The diagnosis is mainly based on the laryngoscope examination and trial of acid suppression therapy. Moreover, recurrence risk is high-with simple operation in VPG therefore the main treatment is a antireflux and it is also valid by replacing byother PPI treatment. The treatment must be long enough. Meanwhile, the comprehensive treatment should be noticed.

Sudden glottic stenosis caused by cricoarytenoid joint involvement due to rheumatoid arthritis

A woman with rheumatoid arthritis (RA) experienced glottic stenosis approximately two months after switching from etanercept to tocilizumab. Cricoarytenoid joint (CAJ) arthritis due to RA was diagnosed. An awake tracheostomy saved the relievable airway, and the administration of methylprednisolone and infliximab ameliorated the flare-up and glottic stenosis. A follow-up examination revealed the recovery of the patient's normal voice and good control of RA with infliximab and methotrexate. Although general physicians do not frequently encounter patients with symptomatic CAJ arthritis, this condition should be considered as it can be life-threatening. Therefore, when detected, it should be diagnosed and treated immediately.

[Clinical analyses of 113 aryepiglottic fold diseases]

OBJECTIVE

To analyze the distribution and treatment of aryepiglottic fold diseases.

METHODS

The clinical data of the inpatients with aryepiglottic fold diseases at our department from January 2000 to May 2011 were retrospectively evaluated.

RESULTS

Among 113 cases, there were benign (n = 108) and malignant (n = 5) diseases. The three major symptoms were abnormal sensation of throat (n = 79), hoarseness (n = 29) and throat pain (n = 26). Among 108 benign cases, there were surgery under direct laryngoscopy (n = 100), aryepiglottic fold hemangioma undergoing laser under indirect laryngoscopy (n = 4), one with cyst and another with hemangioma undergoing tumor removal via an external thyrohyoid membrane approach (n = 2) and inflammation of aryepiglottic fold undergoing conservative treatment (n = 2). Among 5 malignant tumors, the procedures included total laryngectomy (n = 2) and semi-laryngectomy (n = 2). One patient had not any treatment after a definite diagnosis.

CONCLUSION

Most aryepiglottic fold diseases are benign. Their major symptoms include abnormal sensation of throat, hoarseness and throat pain. Surgery under direct laryngoscopy is performed for benign diseases while laryngectomy for malignant ones. CO(2), Ho-YAG and KTP laser may also be used.

Cadaveric position of unilateral vocal cord: a case of cricoid fracture with ipsilateral arytenoid dislocation

We report a case of cricoid cartilage fracture with unilateral arytenoid dislocation following a motorcycle accident. This 25 year old male sustained blunt injury to the head, face and neck. He presented late to the hospital with one week history of dysphonia. Laryngoscopy revealed cadaveric position of the non-functioning left vocal cord. CT and MRI showed laterally displaced left vocal cord. Displaced fractures were noted in the cricoid at the junction of lamina with the anterior arch on the left side and at the right side of the anterior arch, along with dislocated left arytenoid resulting in ipsilateral vocal cord palsy. Medialization thyroplasty was performed to improve his phonation. Laryngeal trauma warrants close monitoring because of the risk of airway compromise. Radiologists play a crucial role in early diagnosis and should always have high index of suspicion. Recognition of laryngeal injury is important for initial resuscitation as well as for long term airway and vocal function.

Laryngeal involvement in juvenile idiopathic arthritis patients

Juvenile idiopathic arthritis (JIA) is an autoimmune diseases characterized by chronic arthritis and systemic manifestations. Autoimmune diseases can affect the upper airways including the larynx. The aim of this study was to investigate laryngeal involvement in JIA patients and its possible association with JIA disease parameters. Fifty consecutive JIA patients were screened for laryngeal abnormalities using flexible fiberoptic laryngoscope and laryngeal computerized tomography. Laryngeal abnormalities were detected in nine (18%) of our cases, with cricoarytenoiditis in six cases (12%) and a rheumatoid nodule in the pyriform fossa in only one case (2%). Diffuse congestion and edema of the posterior part of the larynx with normal vocal cord mobility was detected in two cases (4%). In our study, laryngeal abnormalities were significantly higher in patients with polyarticular seropositive disease subtype and also were significantly higher in patients with longer disease duration, higher disease activity scores, and those with erosive disease. JIA may affect the larynx. Laryngeal involvement in JIA patients is more in polyarticular seropositive cases. JIA patients have to be subjected to thorough otolaryngologic examination for early diagnosis and prompt management.

[Histopathological change of cricoarytenoid joint after laryngeal recurrent nerve paralysis in dogs]

OBJECTIVE

To investigate the histopathological changes in cricoarytenoid joints in 32 animal models. The characteristic histopathological changes of arytenoid cartilages after recurrent nerve paralysis were evaluated.

METHODS

Sixteen dogs (32 vocal folds, 8 as normal control) were divided into different animal models of recurrent nerve paralysis as transection, half-section, ligation, or crush. The histopathological finds of arytenoid cartilages were analysed.

RESULTS

Arytenoid cartilages showed fibrin (12/24), disruption of the fibrous membrane (9/24), fibrillation (7/24) and degenerative changes in their joint surface structure (3/24) at various levels of intensity. The fibrin and disruption of the fibrous membrane were found 1 month after injury, and all changes appeared in 6 months. The fibrillation and arytenoid cartilages degenerative changes revealed in transaction group and ligation group, and became stronger in time of 6 months. The correlation among the fibrillation ratio and the normal control was positive (t were 6.23 and 3.65, P < 0.01). The correlation among the number of cellular of arytenoid cartilages and the normal control was positive (t = 2.78, P < 0.05). The fibrillation (7) and arytenoid cartilages degenerative changes (3) revealed in vocal fold fixation to influence the recovery of laryngeal function.

CONCLUSIONS

The histopathological change of cricoarytenoid joint after recurrent nerve paralysis was related to the severity of neural injury. Influence the recovery of laryngeal function more often from 6 months.

Chondrosarcoma of the arytenoid cartilage

Chondrosarcoma is the most frequently encountered nonepithelial tumor of the larynx. Still, laryngeal chondrosarcoma is a rare disease, accounting for less than 1% of all laryngeal neoplasms; only about 600 cases have been reported in the world literature. The two most common sites of origin are the cricoid cartilage (69% of cases) and the thyroid cartilage (9%); arytenoid cartilage origin has been seen in less than 3% of cases. The diagnosis of laryngeal chondrosarcoma is easy to miss because of its infrequent occurrence, its indolent pattern of growth, and the difficulty in differentiating it histopathologically from chondroma. However, suspicion of arytenoid chondrosarcoma may be raised by a finding of its characteristic appearance as a smooth, hard, mucosa-covered supraglottic mass that is fairly recognizable on indirect laryngoscopy. We report a new case of chondrosarcoma of the arytenoid cartilage in a 47-year-old man, and we discuss the clinical features, diagnosis, and management of this uncommon tumor.

[Clinical features of multiple system atrophy]

This review deals with clinical features of multiple system atrophy (MSA), especially on natural history, sleep disordered breathing, and nocturnal sudden death, based on our recent analyses of definite MSA which we experienced in our institute. Fiberoptic laryngoscopic examination performed under propofol anesthesia revealed that upper airway obstruction is caused not only by vocal cord abductor paralysis but also by various mechanisms including floppy epiglottis and stenosis at the arytenoids during inspiration. We must be cautious not to exacerbate upper airway obstruction by continuous positive airway pressure (CPAP), which is now increasingly used to treat sleep disordered breathing of MSA. Our analyses also demonstrated that nocturnal sudden death was the most frequent cause of death in our MSA cohort, and CPAP could not be a prophylactic measure against sudden death. In order to prevent nocturnal sudden death, a new project is now under way using non-invasive positive airway pressure ventilation (NPPV) and/or artificial ventilation associated with tracheostomy.

Arytenoid dislocation after cardiac surgery

Occurring most usually as complications of upper aerodigestive tract instrumentation during endotracheal intubation or extubation, arytenoid cartilage dislocation and arytenoid subluxation are uncommon laryngeal injuries. Their precise cause, however, is usually difficult to determine. We encountered arytenoid dislocation following cardiac surgery requiring the use of transesophageal echocardiography (TEE). This case prompted us to review some of the mechanisms of injury to the cricoarytenoid joint. We conclude that even very subtle force may dislocate the arytenoid cartilage. We speculate that careless insertion of a TEE probe is mechanically capable of causing arytenoid dislocation and arytenoid subluxation. As ideal tools for intra-operative cardiovascular monitoring, TEE probes are increasingly being used routinely during cardiovascular surgery. So far, arytenoid cartilage dislocation and subluxation following TEE probe insertion have been reported rarely, but complications caused by TEE may increase in the near future. We wish to emphasize the pathophysiological risks of TEE monitoring and other procedures associated with anesthesia, and the need for a proper explanation to achieve informed consent before carrying out TEE monitoring during cardiac surgeries.

Para-arytenoid cartilage pseudodiverticulum formation as a sequela of endotracheal intubation

CONTEXT

Laryngotracheal injury secondary to endotracheal intubation results from ischemic necrosis, which develops within hours of intubation, with injury severity increasing with duration of intubation. Postextubation and postmortem observations demonstrate that laryngotracheal injury still occurs in a large number of intubated patients.

OBJECTIVE

To demonstrate laryngeal injury, specifically pseudodiverticulum formation, as a result of intubation.

DESIGN

A total of 41 autopsy cases from February 1970 to February 2006 were retrospectively reviewed. All patients had been intubated during their hospital course and had an endotracheal tube in place at the time of death. Continuous endotracheal intubation ranged from several hours to 33 days.

RESULTS

The earliest manifestations of laryngeal injury occurred within hours and included hyperemia, edema, and ovoid mucosal lesions over the arytenoid and inner posterolateral cricoid cartilages. Within 48 hours, superficial epithelial denudation progressed to mucosal ulceration, with inflammatory infiltrate into the submucosa. These ulcerations enlarged and deepened, and within 3 to 6 days they showed gross excavations and, in some cases, confluence with other ulcerations. Four cases had pseudodiverticulum formation in the area of the arytenoid cartilages, with deep, excavated lesions that extended to the underlying cartilage. Pseudodiverticulum formation occurred as early as 8 days of continuous intubation.

CONCLUSIONS

Although endotracheal intubation is required for airway maintenance in many patients with respiratory dysfunction, the procedure carries risks. Laryngeal injury from intubation is very common, and the severity of injury is directly related to the duration of intubation. We add para-arytenoid pseudodiverticulum formation to the list of possible complications of endotracheal intubation.

Transnasal laryngoscopy for the diagnosis of laryngeal paralysis in dogs

Four dogs with clinical signs of laryngeal paralysis and three normal dogs were evaluated with transnasal laryngoscopy. Six of these dogs subsequently underwent standard laryngoscopy. For transnasal laryngoscopy, a video endoscope was passed through the left nasal passage after intramuscular sedation and topical anesthesia. The laryngeal opening was observed during spontaneous ventilation. Laryngeal paralysis was diagnosed in four dogs and was confirmed with traditional laryngoscopy in three dogs. Normal motion of the arytenoid cartilages was present in the other three dogs; however, two required mechanical stimulation of the laryngeal mucosa for full evaluation. Transnasal laryngoscopy provided a means for diagnosing laryngeal paralysis in dogs without general anesthesia.

Effects of suture tension during unilateral cricoarytenoid lateralization on canine laryngeal resistance in vitro

OBJECTIVE

To evaluate the effect of abduction suture tension for unilateral arytenoid lateralization on laryngeal resistance.

STUDY DESIGN

Experimental study.

ANIMALS

Canine cadaver larynges (n=16).

METHODS

Laryngeal resistance was calculated in all specimens with the epiglottis in open and closed positions. Left cricoarytenoid lateralization was performed under low or high suture tension, and laryngeal resistance was re-calculated. The effects of suture tension on laryngeal resistance were evaluated by repeated measures ANOVA.

RESULTS

Cricoarytenoid lateralization under low or high suture tension significantly reduced laryngeal resistance with the epiglottis in an open or closed position. There was no difference in laryngeal resistance with an open epiglottis between the low-tension (1.00+/-0.0001 cm H(2)O/L/s) and high-tension (1.10+/-0.35 cm H(2)O/L/s) groups (P=.33). The low-tension group (22.80+/-14.20 cm H(2)O/L/s) had significantly greater laryngeal resistance than the high-tension group (8.45+/-4.00 cm H(2)O/L/s) with a closed epiglottis (P=.016). There was no difference in laryngeal resistance with a closed epiglottis for the low-tension group before (34.30+/-36.50 cm H(2)O/L/s) and after (22.80+/-14.20 cm H(2)O/L/s; P=.42) arytenoid lateralization.

CONCLUSIONS

Cricoarytenoid lateralization under low suture tension significantly reduced laryngeal resistance with an open epiglottis, but resulted in a significantly greater resistance with a closed epiglottis than cricoarytenoid lateralization under high suture tension.

CLINICAL RELEVANCE

Clinically, use of a low-tension suture for cricoarytenoid lateralization may provide an adequate decrease in open-epiglottis laryngeal resistance to alleviate clinical signs, while maintaining enough closed-epiglottis laryngeal resistance to reduce the risk of postoperative aspiration pneumonia.

Ventroaxial luxation of the apex of the corniculate process of the arytenoid cartilage in resting horses during induced swallowing or nasal occlusion

OBJECTIVE

To report ventroaxial luxation of the apex of the left or right corniculate process of the arytenoid cartilage under the contralateral corniculate process during resting endoscopic examination, and morphologic features of the larynx of 1 affected horse.

STUDY DESIGN

Retrospective study.

ANIMALS

Horses (n=8).

METHODS

Horses had endoscopic examination as part of a survey of Clydesdale horses (n=7), or investigation of poor performance in Thoroughbred horses (1). One Clydesdale was euthanatized and the larynx examined; 4 cadaver larynges from normal horses were also examined.

RESULTS

Ventroaxial luxation of the apex of the left or right corniculate process of the arytenoid cartilage was not detected during quiet breathing but was induced by swallowing or nasal occlusion. Prevalence in Clydesdales was 5.2% (7/133). A Thoroughbred with identical endoscopic appearance of the larynx at rest had progressive ventroaxial luxation of the apex of the arytenoid cartilage during high-speed treadmill endoscopy, associated with abnormal respiratory noise. Necropsy examination of an affected Clydesdale larynx revealed an excessively wide (10 mm) transverse arytenoid ligament that allowed easy separation of the apices of the corniculate processes. In normal cadaver larynges, the apices could not be separated with abaxial traction.

CLINICAL RELEVANCE

The clinical relevance of this laryngeal observation in resting horses is unclear. Ventroaxial luxation of the corniculate process of the arytenoid cartilage during induced swallowing or nasal occlusion in resting horses or during high-speed treadmill exercise may be caused by an abnormally wide transverse arytenoid ligament.

Use of successive dynamic videoendoscopic evaluations to identify progression of recurrent laryngeal neuropathy in three horses

CASE DESCRIPTION

3 racehorses were evaluated because of poor performance or abnormal noise originating from the upper portion of the respiratory tract.

CLINICAL FINDINGS

During maximal exercise, initial dynamic videoendoscopy of the upper respiratory tract revealed complete arytenoid cartilage abduction in 2 horses and incomplete but adequate abduction of the left arytenoid cartilage in 1 horse. Subsequent exercising endoscopic evaluation revealed severe dynamic collapse of the left arytenoid cartilage and vocal fold in all 3 horses.

TREATMENT AND OUTCOME

2 horses were treated with prosthetic left laryngoplasty and raced successfully. One horse was retired from racing.

CLINICAL RELEVANCE

Idiopathic laryngeal hemiplegia can be a progressive disease. Successive dynamic videoendoscopic upper airway evaluations were used to confirm progression of left laryngeal hemiplegia in these 3 horses. Videoendoscopy of the upper respiratory tract during exercise should be considered as part of the clinical evaluation of horses with signs of upper respiratory tract dysfunction.

Changes in the Cricoarytenoid Joint Induced by Intubation in Neonates

OBJECTIVE

To characterize the histopathologic characteristics of the cricoarytenoid joint (CAJ) as a means to understand the mechanisms of vocal cord fixation in children after prolonged intubation.

DESIGN

Histologic analysis of laryngeal specimens obtained from infants who had died secondary to various causes and who had been intubated from 1 to 30 days.

MAIN OUTCOME MEASURE

Histopathologic characteristics of CAJ.

RESULTS

Laryngeal specimens from infants who had been intubated for prolonged periods of time demonstrated evidence of hemorrhage, infection, inflammation, and fibrosis within the CAJ. Furthermore, a statistical correlation was found between the length of intubation and the presence of these histologic abnormalities.

CONCLUSIONS

To our knowledge, this is the first study to demonstrate histologic changes in the CAJ in laryngeal specimens of children who have been intubated for prolonged periods of time. Such histological changes in the CAJ could explain the mechanism of vocal cord immobility in children after intubation.

Aggravation of laryngeal rheumatoid arthritis after use of a laryngeal mask airway

We report a case of aggravation of laryngeal rheumatoid arthritis (RA) after the use of a laryngeal mask airway (LMA). The patient was a 55-year-old woman with severe RA who underwent wrist arthrodesis under general anesthesia using a size 3 LMA. A few days after the operation, she reported hoarseness. Inflammation of the arytenoid region and vocal cord immobility were observed by fiberoptic nasolaryngoscopy. Vocal function returned to normal by postoperative day 42 in response to prednisolone therapy. In this case, stridor was misdiagnosed preoperatively, and postoperative symptoms and local findings were probably caused by aggravation of laryngeal RA resulting from substantial compression of the arytenoid region by the LMA. For patients with RA referred for surgery, a careful search for cricoarytenoid arthritis is essential, particularly in those with laryngeal stridor, because it may be aggravated after general anesthesia.

Arytenoid mucosal injury in young Thoroughbred horses — investigation of a proposed aetiology and clinical significance

AIM

To determine whether trauma to the larynx caused by nasotracheal intubation induced mucosal ulceration of the arytenoid cartilages of adult horses, and to determine the incidence of such ulceration in yearling Thoroughbred horses and its effect on athletic performance.

METHODS

Laryngeal trauma was induced in a group of 21 adult horses by introduction of a nasogastric tube into the trachea three times within 5 min. Injury to the arytenoid cartilages or vocal cords was subjectively assessed immediately after intubation, and thereafter at weekly intervals for 10 weeks. The outcome and athletic performance of 33 Thoroughbred yearling horses with idiopathic disease of the arytenoid cartilages, diagnosed at the yearling sales, were evaluated and compared to those of control horses of the same gender and age, from the same sale.

RESULTS

Mucosal injury was noted immediately after intubation in every horse. Evidence of injury to the vocal or corniculate processes of the arytenoid cartilages or vocal cords was still apparent in 10/21 (48%) horses 1 week after intubation, five of which developed persistent lesions that remained present and unchanged from 28 days following intubation until the end of the 10-week observation period. All persistent lesions were nodules or focal swellings of the vocal cords or arytenoid cartilages, and there was no evidence of mucosal ulceration, infection or discharge. Mucosal ulceration of the vocal processes was the most common abnormality detected in the yearlings, affecting 16/33 (48%) that were diagnosed with idiopathic arytenoid disease at the yearling sales. Five of the 33 (15%) horses were diagnosed with arytenoid chondritis at the time of sale and were excluded from the performance outcome analysis. Of the 28 horses diagnosed with arytenoid abnormalities excluding chondritis, 19 (68%) raced with no history of respiratory-related problems, two (7%) were subsequently diagnosed with laryngeal hemiplegia, and seven (25%) were lost to follow-up. The case animals were 2.7 times more likely to race than control horses, but there was no difference between cases and controls in the likelihood of starting more than three times.

CONCLUSIONS

This study showed that nasotracheal intubation in adult horses could result in immediate mucosal trauma, persistent swelling, and focal scarring of the arytenoid cartilages, but this did not mimic mucosal ulceration or chondritis of the arytenoid cartilages observed in yearling Thoroughbred horses. The population studied, however, may not accurately represent the population in which idiopathic disease occurs. In this study, arytenoid mucosal ulceration detected at sale did not commonly progress to arytenoid chondritis. However, a study of a larger population of horses with untreated, naturally occurring disease is required to confirm these findings.

CLINICAL RELEVANCE

It is unlikely that trauma from nasogastric intubation caused arytenoid mucosal ulceration, therefore this procedure should not necessarily be discouraged. This study did not find evidence that horses diagnosed with arytenoid mucosal ulceration at yearling sales had a reduced performance history, therefore it is reasonable to continue to pass horses with uncomplicated arytenoid mucosal ulceration during post-sale endoscopic examination. However, monitoring of the lesions and treatment, if required, may be indicated in the post-sale period.

Arytenoid cartilage dislocation: a 20-year experience

SUMMARY

Arytenoid cartilage dislocation is an infrequently diagnosed cause of vocal fold immobility. Seventy-four cases have been reported in the literature to date. Intubation is the most common origin, followed by external laryngeal trauma. Decreased volume and breathiness are the most common presenting symptoms. We report on 63 patients with arytenoid cartilage dislocation treated by the senior author (RTS) since 1983. Significantly more posterior than anterior dislocations were represented. Although reestablishing joint mobility is difficult, endoscopic reduction should be considered to align the heights of the vocal processes. This process may result in significant voice improvement even long after the dislocation. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography (CT) imaging are helpful in the evaluation of patients with vocal fold immobility to help distinguish arytenoid cartilage dislocation from vocal fold paralysis. Familiarity with signs and symptoms of arytenoid cartilage dislocation and current treatment techniques improves the chances for optimal therapeutic results.

Laryngeal neurilemmoma: a case report

Published reports of benign nerve sheath tumors of the larynx are extremely rare. Because these tumors represent a potential threat to the airway, prompt diagnosis and treatment are vital. We report a case of a neurilemmoma that arose from the right arytenoid muscle adjacent to the arytenoid cartilage. The mass was completely excised, and no recurrence was observed during follow-up. We discuss the diagnosis and management of this rare tumor.

[Extramedullary manifestation of plasmocytoma in ENT]

Plasmocytomas are non-Hodgkin's tumors which occur with an incidence of 4/100,000. Malignant plasma cells in bone marrow produce monoclonal antibodies which are typically found in urine and blood samples. In rare instances plasmocytoma occur exclusively in extramedullary locations preferring head and neck region. We report about two patients with extramedullary plasmocytoma, one of them with an extremely rare triple manifestation in the upper airway.

Partial laser arytenoidectomy in the management of bilateral vocal fold immobility. A modification based on functional anatomical study of the cricoarytenoid joint

OBJECTIVES

To establish the anatomical relationships of the arytenoid and cricoid cartilages and apply these findings to design an arytenoidectomy based on a sound anatomical basis.

METHODS

We prospectively conducted this study between 1996 and 2002 at the Main University Hospital of Alexandria, Egypt. In 50 patients, we endoscopically measured the length of the vocal process and the distance between the vocal process tip and upper border of the cricoid cartilage. We sagittally and axially sectioned 25 total laryngectomy specimens to verify the position of the arytenoids and their relation to the cricoid. The anatomical findings led to the design of a laser partial arytenoidectomy and cordotomy (L-PAC), which we used in 45 patients with bilateral cord paralysis in adduction.

RESULTS

The anatomical findings showed that the cricoarytenoid joint did not contribute to the airway in any of the measured specimens. Using L-PAC, we decannulated 100% of the patients and no patient needed postoperative tracheostomy at any time. Only 3 patients experienced minimal postoperative aspiration to liquids (6.7%). We achieved reasonable phonation as assessed by a speech analysis battery. However, 3 patients (6.7%) needed contralateral L-PAC.

CONCLUSION

The present extra-articular technique, L-PAC, showed its superiority to previous endoscopic or transcervical complete arytenoidectomy techniques in providing an effective balance between the protective, respiratory, and to a lesser extent the phonatory functions.

[CT findings in isolated laryngeal trauma]

The purpose of this article is a retrospective analysis of cases with suspected laryngeal trauma. The clinical importance, possibilities and limits of computertomographic diagnostics in laryngeal trauma are discussed.

PATIENTS AND METHODS

Between 1992 and 2003 we performed high resolution computed tomography (CT) in 7 patients after an isolated laryngeal trauma with a standardized examination protocol.

RESULTS

Following CT findings we made: one fracture of the thyroid cartilage, two fractures of the cricoids cartilage, one luxation of the arytenoids cartilage and four extensive soft tissue swelling of the larynx. One of the patients showed no lesions on CT. In another patient we found an intensive increase of density of arytenoids cartilage as sign of an arytenoids necrosis.

CONCLUSION

High resolution spiral computed tomography is the method of choice to detect or exclude laryngeal fractures after an isolated neck trauma. Special parameters are necessary for detection of subtle pathological findings. In the estimation of mucosal or vocal cord changes the CT is inferior to endoscopy.

[Cricoarytenoid arthritis diagnosed after tracheostomy in a rheumatoid arthritis patient]

A 65-year-old woman was scheduled for total knee replacement. She had been suffering from rheumatoid arthritis for 22 years. She also had a history of occasional acute dyspnea, which had been diagnosed as asthmatic bronchitis. Preoperative examinations of the airway revealed limited neck flexion, a small jaw, and normal mouth opening. After epidural catheterization, anesthesia was induced with propofol, and a #3 laryngeal mask airway (LMA) was inserted. However, her lungs could not be ventilated through the LMA. Despite repeated attempts, proper placement of the LMA could not be achieved. Hence, a 7.0 mm ID armored endotracheal tube was inserted through an intubating LMA. Anesthesia was maintained with nitrous oxide and sevoflurane in oxygen. The surgery proceeded uneventfully. Five minutes after extubation, inspiratory dyspnea occurred. The patient's trachea was re-intubated nasally with a bronchofiberscope. Since the bronchofiberscopy revealed remarkable laryngeal edema, percutaneous tracheostomy was performed. On the 3 rd postoperative day, cricoarytenoid arthritis that had caused occasional airway obstruction was diagnosed, although her laryngeal edema disappeared. She went home with a permanent tracheostomy. Although cricoarytenoid arthritis is a common occurrence in patients with rheumatoid arthritis, the diagnosis can be difficult. A scrupulous preoperative evaluation and awareness of cricoarytenoid arthritis are necessary for optimal anesthetic management.

Laryngeal anatomic differences in pediatric patients with severe laryngomalacia

OBJECTIVES

To compare the aryepiglottic (AE) length in pediatric patients who have severe laryngomalacia (SL) and are undergoing aryepiglottoplasty with the AE length of a convenience sample of control patients without laryngomalacia.

DESIGN

Prospective case-control study.

SETTING

A tertiary-care pediatric hospital.

RESULTS

The mean AE fold length-glottic length ratio for patients with SL (0.380) was significantly lower than the mean ratio for controls (0.535) (P = .004 in 2-sample t test with unequal variance). For patients with SL, the aryepiglottoplasy procedure resulted in an average AE length increase-glottic length ratio of 0.330. Seven of the patients with SL were also diagnosed as having an underlying neurologic condition, and 18 had a diagnosis of gastroesophageal reflux disease. Two patients with SL required a tracheotomy for treatment of persistent airway obstruction.

CONCLUSIONS

In this series, patients with SL had lower AE fold length-glottic length ratios and more frequent occurrence of neuromuscular tone abnormalities (especially gastroesophageal reflux) than controls. These 2 findings may be related in that low intrauterine tone might contribute to anatomic underdevelopment.

Laryngeal involvement in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting the synovial membrane, which causes joint damage and bone destruction. Extra-articular manifestations are numerous, involving multiple organ systems. Rheumatoid nodules are common extra-articular findings occurring in 20% RA patients. They develop most commonly in pressure areas (elbows and finger joints) and may occasionally affect internal organs including pleura, lungs, meninges, larynx, and others. Furthermore, RA affects the ear, nose, and throat, causing various otorhinolaryngological symptoms. In this report we describe two patients with RA and laryngeal involvement, mostly rheumatoid nodule formation, with a review of the literature.

Cricoarytenoid arthritis in Sjögren’s syndrome

We present the case of a 50-year-old female with polyarthralgias and dysphonia. Indirect laryngoscopy revealed the presence of cricoarytenoid arthritis. The patient complained of dryness of the eyes and oral mucosa and was diagnosed with Sjögren's syndrome. Treatment with prednisolone quickly brought remission of systemic and laryngeal symptoms as well as improvement in the results of video-laryngostroboscopic tests. Laryngeal involvement is uncommon in Sjögren's syndrome. One case with vocal nodules, one with lymphocytic infiltration of the larynx, and one with repeated false cord swelling have been previously reported.

Neoplastic invasion of laryngeal cartilage: the significance of cartilage sclerosis on computed tomography images

Cartilage sclerosis has been cited as a sensitive and a specific sign of neoplastic cartilage invasion, on cross-sectional computed tomography (CT) images of the larynx. We retrospectively reviewed 36 consecutive patients, who underwent a total laryngectomy for squamous cell carcinoma of the larynx. Preoperative CT images were compared with formal histological sections of the larynx in order to assess cartilage invasion by tumour. Isolated asymmetrical cartilage sclerosis was found to have a sensitivity of 62% and a specificity of 42% for predicting neoplastic cartilage invasion when compared with histopathological sections of the tumour. In this study we found that cartilage sclerosis was not a useful early radiological sign of neoplastic cartilage invasion when taken in isolation.

[Granular cell tumor (Abrikosov's tumor) of the larynx--literature review and 2 case reports]

Granular cell tumors are uncommon neoplasms of the head and neck and they are rare in the larynx. About 200 cases had a laryngeal setting. The origin of these tumors is still unknown, but most authors believe it to be neural in origin. Authors described two laryngeal sites of granular cell myoblastoma. In the first case (44 year old man) tumor was located at the vocal fold. It was removed by laryngofissurae. In the second case (56 year old woman) tumor was located at the arytenoid cartilage and was removed radically during Kleinssaser directoscopy.

Idiopathic mucosal lesions of the arytenoid cartilages of 21 Thoroughbred yearlings: 1997-2001

REASONS FOR PERFORMING STUDY

Mucosal ulcers and, occasionally, small granulomas on the axial surface of one or both arytenoid cartilages have been found in TB yearlings presented for post sale endoscopic examination.

OBJECTIVES

To determine the incidence, endoscopic characteristics and outcome of a group of Thoroughbred yearlings affected with mucosal ulcers and granulomas of the arytenoid cartilage.

HYPOTHESIS

The incidence of mucosal ulceration of the arytenoid cartilages of yearling Thoroughbreds is relatively high compared to other upper airway abnormalities; and that the majority of mucosal ulcers heal uneventfully, although a small percentage may progress to a granuloma and, less commonly, to arytenoid chondropathy.

METHODS

The findings of post sale, upper airway endoscopic examinations of 3312 Thoroughbred yearlings, during a 5 year period, were reviewed, including those abnormalities listed in the conditions of sale and others not listed but considered likely to cause airway obstruction. Information obtained from the medical record of horses that had mucosal ulceration or granuloma of the arytenoid cartilage included the location and size of the lesion(s), sex of the affected horse and the presence and nature of other concurrent abnormalities of the upper portion of the respiratory tract. Additional information included treatment and results of follow-up, endoscopic examination by the authors or attending veterinarian.

RESULTS

Mucosal lesions were seen in 0.63% of yearlings evaluated, which represented the most common, documented condition of the upper portion of the respiratory tract. The mucosal ulcers of 15 of 19 horses were considered to have healed without complication during follow-up examination; one of the 19 horses was lost to follow-up. Two horses affected with bilateral, arytenoid mucosal ulceration developed a granuloma at each site of ulceration. One horse developed a granuloma at a site of ulceration and, subsequently, arytenoid chondropathy.

CONCLUSIONS

Arytenoid mucosal ulceration in sales yearlings was a relatively commonly encountered abnormality and a small percentage progressed to granuloma or chondropathy.

POTENTIAL RELEVANCE

The mucosa of the arytenoid cartilage, particularly at the rostral margin of the vocal process, should be examined carefully during endoscopic examination of the upper portion of the respiratory tract of Thoroughbred yearlings presented for sale. Because a small percentage of mucosal ulcers may progress to granuloma or, less commonly, chondropathy, identification of mucosal ulcers of the arytenoid cartilage seen during post sale, endoscopic examination warrants notification to the purchaser and sales company. Medical therapy of affected horses should be considered and follow-up endoscopic examination performed to determine if the lesion has healed.

The effect of two modifications of unilateral arytenoid lateralization on rima glottidis area in dogs

OBJECTIVES

To evaluate the clinical outcome and percentage increase in rima glottidis area achieved using a combined technique of cricoarytenoid and thyroarytenoid cartilage lateralization compared with cricoarytenoid cartilage lateralization alone in live anesthetized dogs clinically affected with bilateral laryngeal paralysis.

STUDY DESIGN

Randomized prospective clinical study.

ANIMALS

Twenty dogs with bilateral laryngeal paralysis. Methods-Bilateral laryngeal paralysis was diagnosed by direct laryngoscopy. Each dog was allocated randomly to 1 of 2 surgical groups: CAL (cricoarytenoid lateralization) and CTAL (cricoarytenoid and thyroarytenoid lateralization). Photographs were taken of each larynx before and after surgery, the images were digitized, and the preoperative and postoperative areas of each rima glottidis were measured. The percentage increase in rima glottidis area produced by each of the arytenoid lateralization procedures was compared. Follow-up was obtained by telephone survey of owners and referring veterinarians.

RESULTS

There was no significant difference in mean (+/- SD) percentage increase in rima glottidis area for the CAL group (241.5 +/- 42.9%) or the CTAL group (236.4 +/- 44.5%). Clinical follow-up (median, 18 months postoperatively) indicated 60% of the dogs were still alive and only 1 dog had died as a result of complications related to surgery.

CONCLUSIONS

CTAL for the treatment of canine laryngeal paralysis does not significantly increase rima glottidis area compared with CAL alone. The mean percentage increase in rima glottidis area obtained with both procedures was comparable to previously reported mean increases with CAL in live anesthetized dogs. Both procedures resulted in good long-term clinical outcome.

CLINICAL RELEVANCE

CTAL is as effective as CAL in providing an increased rima glottidis for the treatment of bilateral laryngeal paralysis in dogs.

Effects of suture tension and surgical approach during unilateral arytenoid lateralization on the rima glottidis in the canine larynx

OBJECTIVES

To evaluate the effect of abduction suture tension and cricothyroid (CT) joint disarticulation on the area, height, and width of the rima glottidis (RG) during unilateral arytenoid lateralization.

STUDY DESIGN

Experimental study.

ANIMALS

Nine canine cadaver larynges.

METHODS

Left arytenoid lateralization was performed with high or low abduction suture tension. RG area, height, and width were measured by computerized planimetric analysis with the epiglottis in an open and closed position. The experiment was performed with the CT joint intact and disarticulated. The effects of suture tension, CT disarticulation, and their interaction on RG area with the epiglottis closed or open were evaluated by repeated measures analysis of variance (ANOVA).

RESULTS

RG area increased by 82% and 129% (P <.0001) with low and high suture tension, respectively. The aperture not covered by the epiglottis in a closed position was 467% larger with high suture tension than with low tension (P <.0001). CT disarticulation had no significant effect on RG geometry with either low or high suture tension (P =.4970).

CONCLUSIONS

Low suture tension increased RG area when the epiglottis was in an open position without increasing RG aperture when the epiglottis was closed. Suture tension had a significant effect on RG opening when the epiglottis was closed. CT disarticulation did not modify the geometry of the RG.

CLINICAL RELEVANCE

Use of a low-suture tension should be considered during arytenoid lateralization because it has the potential to reduce the risk of aspiration pneumonia.

Impact of vocal cord paralysis on cricoarytenoid joint

To demonstrate structural changes in the cricoarytenoid joint after recurrent laryngeal nerve paralysis, we performed a laboratory investigation of fixed arytenoid cartilages from adult humans obtained during laser surgical arytenoidectomy in cases of bilateral vocal fold paralysis, analyzing the articular cartilage, the joint capsule, and the attached laryngeal musculature. Ten arytenoid cartilages from adult humans were studied by means of histology, as well as scanning and transmission electron microscopy. After long-standing denervation (>6 months), all arytenoid cartilages showed degenerative changes in their joint surface structure at various levels of intensity. The articular surface revealed fibrillation in some places, demasking of collagen fibrils next to the joint surface, and formation of chondrocyte clusters near the joint surface. All specimens also showed muscle atrophy. We conclude that long-standing recurrent laryngeal nerve paralysis does not result in ankylosis of the cricoarytenoid joint, as assumed, but the articular cartilage undergoes structural changes comparable to those in osteoarthritis. Structural changes in the articular cartilage and in the surrounding musculature hamper efforts at joint function recovery, as do procedures aiming solely at either medialization or lateralization of the vocal fold.

Cricoarytenoid arthritis: a cause of acute upper airway obstruction in rheumatoid arthritis

PURPOSE

To report acute upper airway obstruction due to cricoarytenoid arthritis, a well known but uncommon complication of rheumatoid arthritis.

CLINICAL FEATURES

We report the case of a 70-yr-old female scheduled for a colostomy who had been suffering from rheumatoid arthritis for 17 years. Preoperative history and physical examination revealed no cardiopulmonary compromise. Anesthesia was induced while an assistant immobilized the cervical spine and an atraumatic intubation was performed. Surgery was uneventful. Muscle paralysis was reversed, demonstrated by normalization of the train-of-four response, and the patient was extubated awake. Shortly postextubation, the patient developed inspiratory stridor, which disappeared after a second dose of neostigmine. The patient was transported to the postanesthesia care unit. Just prior to arrival the patient once again developed inspiratory stridor, became distressed, and oxygen saturation decreased. Direct laryngoscopy followed by a nasal fibreoptic examination of the larynx was performed. Cricoarytenoid arthritis secondary to rheumatoid arthritis with airway compromise was diagnosed. An uneventful awake tracheostomy was performed. The patient was discharged on day ten with a colostomy and a tracheostomy in place. One month postdischarge the patient's trachea was decannulated. On follow-up, a normal voice and mobile cords were observed.

CONCLUSION

Cricoarytenoid arthritis is an infrequent complication of rheumatoid arthritis. A thorough history and physical examination are necessary to recognize signs and symptoms of cricoarytenoid arthritis. Prompt recognition of airway obstruction due to cricoarytenoid arthritis is essential for appropriate management.

Laryngeal manifestation of gout: a case report of a subglottic gout tophus

A subglottic tophaceous deposition of urate crystals is a rare finding. We report on a case of a male Caucasian who had a moderate dysphonia without any further laryngeal symptoms. The laryngoscopy revealed a hemispheric lesion on the left subglottic region. An excision biopsy was performed, and the histopathological examination of the dissected specimen showed a tophus. Diagnostic and therapeutic strategies are discussed.