Hyoid Bone and Thyroid Cartilage Fractures at Forensic Autopsies

ABSTRACT

Fractures of the hyoid bone (HB) and thyroid cartilage (TC) are important findings in emergency medicine and forensic pathology. This study aimed to determine the occurrence and anatomical localization of HB and TC fractures and to evaluate the etiological and risk factors.A total of 315 patients with HB and/or TC fractures were included over a 3-year period. Data regarding the incident type, cause of death, age, sex, body mass index, regional trauma findings, location of fractures, resuscitation, and toxicological analyses were collected. Injury severity scores were calculated using the Abbreviated Injury Scale.The study found that HB and TC fractures were associated with trauma severity. The hanging cases exhibited the highest number of fractures. A significant association was observed between neck trauma localization and HB and TC fractures. Fractures of the HB and TC horns were more commonly associated with neck trauma than fractures of the corpus. Hyoid bone and TC fractures can occur without direct trauma, emphasizing the importance of thorough examination and diagnosis, particularly after cardiopulmonary resuscitation.This study provides valuable insights into HB and TC fractures and contributes to the understanding and identification of these fractures in forensic autopsies and clinical settings.

Chondrosarcoma of the thyroid cartilage: surgical management of a rare case

Laryngeal malignancy encompasses about 1% of all cancers. Chondrosarcoma in the head and neck region represents about 0.1% of head and neck malignancies. Typical presenting symptoms relate to the anatomical location of these tumours and include dysphonia, inspiratory stridor, dysphagia, odynophagia or a neck mass. Benign and malignant cartilaginous cancers of the larynx have been described, and preoperative diagnosis can be difficult. Our report highlights the surgical management of a male patient in his 50s with chondrosarcoma of the thyroid cartilage.

Laryngeal Chondrosarcoma of the Thyroid Cartilage

Laryngeal chondrosarcoma is rare and accounts for 0.2% of all larynx malignancies. Although chondrosarcoma is the most common sarcoma seen in the larynx, laryngeal involvement by cartilage tumors is rare. In this article, we aimed to present the differential diagnosis of chondrosarcoma located in the thyroid cartilage, which is a rare site, in a 75-year-old male patient. The patient underwent total laryngectomy by the otolaryngology department. The macroscopy of the laryngectomy material sent to the pathology laboratory revealed a 3x2 cm tumor with a polypoid extension to the lumen from the bottom of the right vocal cord. Although clinical and radiological findings are important in the diagnosis, the definite diagnosis is based on the pathological examination. It is especially important to differentiate the lesion from chondromas.

Two Different Tracts and Origin of Pyriform Sinus Fistula

OBJECTIVE

Suppurative acute thyroiditis is caused by pyriform sinus fistula (PSF), and PSF frequently elicits deep neck abscess. However, complete fistulectomy is the ideal management of PSF, and studies on surgical findings of PSF are exceedingly rare. This study aimed to reveal the origins of PSF, each route, and clinical presentation.

METHODS

This is a multicenter study. We have conducted 19 complete fistulectomies of PSF in Japan, analyzed routes of the fistulas, estimated the origins, and investigated their histological and clinical findings.

RESULTS

No recurrence was observed in all cases. Five of 12 cases showed thymic and/or parathyroid tissues around the fistulas, passing inside the inferior horn of thyroid cartilage, were regarded as having 3rd pouch origin, and tended to have low frequency of severe deep neck abscess. The remaining 7 cases originated from the 4th pouch running outside of the horn and showed frequent severe infection.

CONCLUSION

PSF have 2 different routes depending on their generation and may present different clinical manifestations.

The added value of postmortem magnetic resonance imaging in cases of hanging compared to postmortem computed tomography and autopsy

The purpose of this study was to evaluate the added value of postmortem magnetic resonance imaging (MRI) compared to postmortem computed tomography (CT) and autopsy in cases of fatal hanging. In addition, the study analyzed the strengths of each examination method regarding typical injuries in these cases. We investigated a cohort of 25 decedents who underwent CT, MRI and autopsy. Two radiologists assessed all MR images of the head and neck as well as the corresponding CT images. The results were compared to autopsy findings by retrospectively analyzing the autopsy reports. Postmortem MRI revealed intramuscular hemorrhages in a large number of cases, however, autopsy did not confirm all of the detected hemorrhages. CT and autopsy detected fractures in several cases, whereas MRI showed a fracture in just one single case. Other previously described vital signs and relevant findings, such as fracture-related gas bubbles, soft tissue emphysema or pneumomediastinum, were observed in only a few individual cases. MRI provided added diagnostic value in the detection of soft tissue injuries and lymph node swelling in fatal hangings. As an adjunct to autopsy, postmortem MRI may reveal additional hemorrhages, which might be missed at autopsy. Since standard MRI demonstrated low sensitivity for the detection of fractures, an additional imaging modality or autopsy is required to overcome this limitation.

Thyroid Cartilage Cysts, A Rare Entity Causing Dysphonia

Five cases are presented with a strained voice quality due to a unique underlying cause: thyroid cartilage cysts. Laryngoscopy and radiological images show antero-medial displacement of both vestibular and vocal fold(s). Swelling in the ala of the thyroid cartilage results in a pear-shaped lumen. These cysts were marsupialized with CO₂ laser, fluid emerged, and histological biopsies confirmed cartilaginous cysts. Postoperatively, all cases report largely reduced or completely resolved vocal complaints, with a consistent follow-up of 2 years. Together with previous publications, an overview of 17 cases is presented, to enhance awareness that thyroid cartilage cysts can cause a strained voice quality. Laryngoscope, 130:E628-E631, 2020.

Laryngeal gout mimicking chondrosarcoma with concurrent longus colli tendinitis

A 42-year-old man with multiple comorbidities, including gout, presented to the emergency department with severe odynophagia for 4 days with intermittent dysphagia for 1-2 months. A CT scan of the neck showed right longus colli tendinitis and partially calcified excrescences from the right thyroid cartilage which raised suspicion of a cartilaginous tumour. He underwent an MRI scan of the neck to better evaluate the thyroid cartilage findings, which showed a heterogeneous mass suspicious for a chondroid tumour. He then underwent a positron-emission tomography-CT scan which showed a fluorodeoxyglucose-avid mass containing foci of calcification involving the right thyroid cartilage and adjacent strap muscle, with high standardised uptake value of 7.7. He subsequently underwent a CT-guided biopsy and an open biopsy of the right thyroid cartilage, and the results revealed gouty tophi. To our knowledge, this is the first reported case of laryngeal gout with longus coli tendinitis, both of which are rare conditions.

Morphological Evaluation of Thyroid Cartilage Invasion in Early Glottic Tumors Involving the Anterior Commissure

INTRODUCTION

The anterior commissure is an area of glottic cancer infiltration, even in early stages.

OBJECTIVE

To evaluate the invasion by tumors into the anterior commissure cartilage in surgical specimens of frontolateral laryngectomy.

METHODS

Forty-eight patients who had undergone frontolateral laryngectomy for T1b/T2 squamous cell carcinoma were included. Epidemiological and clinical aspects as well as morphological histopathological analysis were evaluated.

RESULTS

Of the 48 patients, 42 (87.5%) had T1b lesions and 6 (12.5%) had T2. Thirty-four cases (70.8%) showed healthy tissue between the tumor and the thyroid cartilage, 10 cases (20.8%) had a tumor in close proximity to the cartilage, and in 4 cases (8.3%) there was cartilage invasion. There was no major risk of adverse outcome in the groups with infiltration or tumor adjacent to the cartilage. Level of differentiation, mitotic index, nuclear irregularity, and the presence of nucleolus and tumor necrosis were not related to cartilage invasion.

CONCLUSION

The infiltration of thyroid cartilage occurred in 8.3% of tumors and did not change the outcome in patients submitted to frontolateral laryngectomy. The morphological characteristics did not present any statistical significance.

[The forensic medical characteristic of the age based on the results of the comprehensive examination of the thyroid cartilage]

The objective of the present study was the development of the diagnostic model for determining the human age based on the results of the comprehensive examination of the 230 thyroid cartilages (TC) obtained from the corpses of men and women of different age. TC were examined with the use of the anthropometric, X-ray, and histological methods. The anthropometric investigations confirmed the gender-related differences in the structure of human TC. Various characteristics of TC were shown to correlate with the age but these relationships were rather weak even if formally significant. The X-ray studies of TC have revealed the significant correlation of the relative amount of the bone tissue on the images with the age (r=0.8). Of the 27 parameters subjected to the morphometric evaluation, the following ones were shown to significantly correlates with the age: percentage of the bony (r=0,82) and cartilaginous (r=-0.8) tissue areas, average density of the adipose (r=0.76) and reticular (r=0.7) tissues, the maximum length of trabeculae (r=0.67), the width of the mature cartilage zone (r=0.54), the cortical plate thickness (r=0.5), and the mean number of immature chondrocytes in the field of vision (r=0.5). The comprehensive investigation into the structure of the human thyroid cartilage provided a basis for the development of the method for determining the human age with the use of the linear regression equations. It is concluded that the proposed method can be employed as an additional diagnostic tool for determining the human age for the purposes of forensic medical expertise and personality identification.

[The age-specific changes in the histological structure of the thyroid cartilage in the men]

The objective of the present study was to elucidate the morphological and morphometric characteristics of the human thyroid cartilage during different periods of life. The thyroid cartilages were harvested from 70 cadavers of the subjects of the masculine gender who had died at the age from 1 to 93 years from the non-violent causes and had neither injuries nor signs of pathological changes in the neck organs. The microscopic studies were carried out using the standard methods for the staining of the preparations with hematoxylin and eosin. The following parameters were evaluated: the area of the cartilaginous and bone tissues, the average area of the cartilaginous and bone tissues in the field of vision, the average width of the cartilaginous plate, the thickness of the cortical plate, the number of trabeculae, the average area and length of the trabeculae, the average, minimal, and maximum area of the trabeculae, the number of the young and mature chondrocytes, the width of the zones of the young and mature cartilage and their ratio, the area of the reticular-fibrous and adipose tissues and their ratio. In addition, we also determined mean values, standard deviations, correlation coefficients, and the significance of differences (p). The following characteristics exhibited the most significant correlation with the age: the average area of the bone (r=0.69) and cartilaginous (r=-0.63) tissues, adipose (r=0.67) and reticular fibrous (r=0.61) tissues, the average length of the trabeculae (r=0.7), the number of young chondrocytes in the field of vision (r=-0.789). It is concluded that the described correlations can be helpful in the practical forensic medical activities as the additional diagnostic criteria for the determination of the human age.

Fatal laryngeal oedema in an adult from an air rifle injury, and related ballistics

Air guns (air pistols and rifles) are already recognized as being potentially lethal. The diabolo pellet has a calibre of .177 (4.5 mm), a 1250 fps velocity, is high energetic, and is most commonly used in such weapons. In the presented case, the victim sustained an air rifle injury to the neck. The pellet passed through the thyroid cartilage, subsequently causing the extensive laryngeal swelling with haematoma around the pellet channel which fatally obstructed the airway. It is estimated microscopically that at least a number of hours must have passed from the injury to the time of death. For this case, a shooting distance was estimated by using experimental shooting values compared to physics formulas for accelerated motion. The case under question has confirmed an applicable legal approach that can be utilized by countries to classify air rifles as being as harmful as other firearms, especially those with high muzzle velocities.

[Superior horn of thyroid cartilage dysplasia in 1 case]

The external stimuli and other reasons may result in hyperplasia and abnormal angle of the upper corner of the thyroid cartilage. The upper corner of the thyroid cartilage has anatomical variations. To oppression stimulate carotid artery, cervical sympathetic dry section and so on, could causing pharyngeal foreign body sensation and sore throat. By surgical removal of the thyroid cartilage hyperplasia upper corner, postoperative symptoms would be resolved.

Primary laryngeal clear cell chondrosarcoma: report of a case and literature review

We present an example of clear cell chondrosarcoma (CCC) arising in the thyroid cartilage, and review the literature regarding this neoplasm in the larynx. This patient has no evidence of disease 3 years post hemilaryngectomy. Although rare and morphologically distinct, CCC follows the same benign clinical course as conventional laryngeal chondrosarcoma.

Role of biopsy in low-grade laryngeal chondrosarcoma: report of two cases

Laryngeal chondrosarcomas are rare tumours that account for less than 1% of all sarcomas and originate principally from the crycoid cartilage. We report two cases: the former arising from thyroid cartilage in an 85-year-old male presenting with a palpable neck mass and hoarseness, dyspnoea and dysphagia; the other in a 54-year-old male with a mass growing from crycoid cartilage, who underwent biopsy followed by total laryngectomy. We discuss the peculiarity of the site of origin and the role of biopsy, the clinical presentation of the former case and the diagnostic and therapeutic procedures of the latter. Since it is a rare form of sarcoma arising in the larynx, we discuss the role of biopsy as a crucial although still controversial diagnostic tool.

Causes of laryngeal cartilage and hyoid bone fractures found at postmortem

The principal aims of this retrospective study were to assess the prevalence and causes of laryngo-hyoid fractures found in coroners' adult postmortem examinations over a five-year period. In 78 of 1930 cases (4%), there was a fracture of the larynx (thyroid or cricoid cartilage) or hyoid bone. The thyroid cartilage alone was fractured in 38 cases; the hyoid bone alone was fractured in 19 cases; the larynx and hyoid bone were both fractured in 21 cases, including one which involved the cricoid cartilage. There was no evidence of surface injury to the neck in 14.1% of cases. The majority (44/78; 56.4%) involved classical manual or ligature 'pressure to the neck', i.e. hanging (32) or strangulation (12) but a significant minority (35.9%) involved other circumstances: road/rail traffic collision (12; 15.4%); falls (6; 7.7%); assaults involving blunt force trauma to the head and neck (4; 5.1%); incised wounds (3; 3.8%); gunshot wounds (2; 2.6%); and explosion (1; 1.3%). The circumstances of death and cause of fracture(s) were 'unascertained' in four cases (5.1%). Postmortem artefact accounted for two cases (2.6%).

Hyoid-laryngeal fractures in hanging: where was the knot in the noose?

The aims of this study were to determine the frequency of hyoid-laryngeal fractures in hanging in relation to the position of the ligature knot, to reconstruct the location of the ligature knot in cases of hanging when the furrow is not detectable on the skin, and to identify the possible mechanism of neck structure injuries. We report a retrospective autopsy study which included 557 cases of suicidal hanging: 413 men and 144 women, with an average age of 52.4 +/- 17.8 years. In 57.3% of them, hyoid-laryngeal fractures were found (average age was 54.3 +/- 16.5 years): 15.1% had only hyoid bone fracture, 26% had only thyroid cartilage fracture and 16.2% had both types of injury at the same time. Hyoid-laryngeal fractures were found more often in persons aged over 30 years. Hyoid bone fracture was a weak predictor of ligature knot position in our sample. Fracture frequencies of the thyroid cartilage show a statistically significant difference in relation to the ligature knot position among persons older than 30 years, which indicated the ipsilateral and posterior position of the knot. Absence or presence of any form of hyoid-laryngeal fracture indicated that knot position was anterior or posterior, respectively. The derived data would be useful for cases where the ligature has been removed from the body of the deceased shortly after hanging, where the noose is unavailable, and in cases where the ligature mark has faded such as with soft ligatures removed promptly or in decomposed bodies.

Fractures of the hyoid bone and thyroid cartilage in suicidal hanging

OBJECTIVE

To analyze the frequency of hyoid bone and thyroid cartilage fractures caused by suicidal hanging in Thai people and compare the different methods of visualizing the those fractures. Results could be used for forensic purposes.

MATERIAL AND METHOD

A prospective study of hyoid bone and thyroid cartilage fractures in Thai people who died from suicidal hanging between November 2008 and August 2009. The authors confirmed suicides, based on history, crime scene investigation, autopsy reports, and other police information, visual and palpatory examination, and stereomicroscopy with or without 1% Toluidine. Neck dissection was performed following the protocol of Prinsloo and Gordon. Results and data analysis were performed via SPSS version 16.

RESULTS

Twenty male cases of suicidal hanging were reviewed. Fractures of the hyoid bone and/or thyroid cartilage were found in five cases (25%). Two cases ofthe hyoid bone fracture, two cases of thyroid cartilage fracture, and one case was both bone fractures. Mean age of all cases, non-fracture, and fracture cases were 42.40, 35.93, and 61.80 years, respectively The knot was at the back of the neck in most cases (12 cases, 60%) and at the left, front, and right in four, two, and two cases, respectively. However there was no relation between location ofthe knot at the neck and fractures of hyoid bone and thyroid cartilage (p=1). Incomplete and complete hanging were found in 11 and nine cases. Five cases with fractures of the hyoid bone and/or thyroid cartilage were incomplete hanging. The visual and palpatory examination did not detect the fracture of hyoid bone in all 20 cases but stereomicroscopy and stereomicroscopy with Toluidine blue stain detected fracture in three cases. For detecting thyroid cartilage fractures, all three methods had the same result.

CONCLUSION

Fractures of the hyoid bone and thyroid cartilage in 25% of Thais who died of suicidal hanging were related with older ages and incomplete hanging but not related with location of the knot. The stereomicroscopic method is fast and effective in detecting fractures of the hyoid bone and thyroid cartilage.

Type III thyroplasty for the treatment of glottic gap in a patient undergoing laryngofissure cordectomy for squamous cell carcinoma of the vocal fold: technique and outcome

A 44-year-old man presented with squamous cell carcinoma (T1aN0M0) on the left vocal fold and was prepared for a combined laryngofissure cordectomy and type III thyroplasty. The author performed both procedures together-not only to lower the tension on the healthy vocal fold, but also to determine whether the thyroplasty would successfully close the glottic gap created by the cordectomy, resulting in relatively fast improvement in the patient's voice. Satisfactory glottic closure and a satisfactory voice result were achieved rather quickly. The patient was satisfied with his new voice, both in the early and late postoperative periods.

Ultrasonographic evaluation of hyoid-larynx approximation in dysphagic stroke patients

Hyoid-larynx approximation is an essential part of the swallowing process, and is related to airway protection. We aimed to evaluate the reliability of ultrasonographic examination of hyoid-larynx approximation and measure the approximation in stroke patients with or without dysphagia. Fifteen normal subjects and 40 stroke patients with or without dysphagia admitted to the Department of Rehabilitation Medicine of a tertiary hospital between July 2006 and February 2007 participated in this study. The distance between the thyroid cartilage and hyoid bone during swallowing was measured by ultrasound. Hyoid-larynx approximation was defined as the distance obtained by subtracting the shortest distance between the hyoid bone and thyroid cartilage during swallowing from the initial resting distance. Ten stroke patients with dysphagia also underwent standard videofluoroscopic swallowing study (VFSS). The change percentage of hyoid-larynx approximation was very similar between ultrasonographic examination and VFSS. There was no significant difference in resting distances between the thyroid cartilage and hyoid bone between normal subjects and stroke patients with or without dysphagia. Among stroke patients, hyoid-larynx approximation was less in the dysphagia group than in the nondysphagia group. In conclusion, ultrasound can quantitatively measure hyoid-larynx approximation with good reliability. Hyoid-larynx approximation was significantly reduced in stroke patients with dysphagia.

[Cable tie used for suicidal ligature strangulation--a case report]

Based on a case of self-strangulation committed with two connected cable ties, criteria for the differentiation of homicidal and suicidal ligature strangulation are discussed. Differentiation may be difficult and demands close cooperation between the police and the forensic experts. Apart from the history and general circumstances of the case, not only the kind of strangulation, but also the presence of any concomitant injuries, the degree of congestion and any internal injuries are of relevance for the criminalistic evaluation. As self-strangulations are rare, these cases demand special attention.

Anterior Vocal Commissure Invasion in Laryngeal Carcinoma Diagnosis

BACKGROUND

Laryngeal carcinoma involving anterior vocal commissure (AVC) represents a great challenge for staging and treatment.

OBJECTIVES

To compare laryngoscopy and computed tomography (CT) scan efficiency in staging tumors extending to the AVC. We also analyzed the helicoidal axial CT scan accuracy in recognizing this larynx subregion invasion.

MATERIAL AND METHODS

Fifty-two glottic and supraglottic laryngeal squamous cell carcinoma patients with tumoral extension to the AVC were prospectively studied from August 2001 to August 2003 at the National Cancer Institute (Rio de Janeiro, Brazil). All patients underwent videolaryngoscopic examination and direct laryngoscopy for lesion extension analysis and biopsy. After AVC helicoidal axial CT scan with sagittal and coronal 1.0 mm thick reconstruction, patients were submitted to surgical treatment. The same pathologist analyzed all surgical specimens.

RESULTS

When compared with pathologic stage, clinical endoscopic classification was correct in 40.38% of cases (40% for T1, 29.41% for T2, 46.43% for T3, and 50% in T4). Helicoidal axial CT scan accuracy for AVC tumors was 75% (P = .0001), being more important for T2 (62.50%), T3 (73.91%), and T4 (88.24%) lesions. Identification of radiologic signs described as gross radiologic anterior commissure involvement (GRACI) increased radiologic image staging accuracy to over 96%.

CONCLUSIONS

Endoscopic evaluation understaged tumors in all clinical stages but really T1. Helicoidal axial CT scan reformatted to 1.0 mm thick played an important role in correctly staging more advanced AVC laryngeal tumors. Radiologic signs, here identified as GRACI, may be very helpful for tomographic staging and patient treatment.

A case of death from the explosion of a 66mm M72 High Explosive Anti-Tank rocket

A 53-year-old male died from an explosion of a 66 mm M72 High Explosive Anti-Tank (HEAT) rocket. He had collected various cast-off military weapons and was selling them. There were numerous explosive injuries on the anterior side of the body, thus especially bilateral hands, left toe and right knee were severely crushed and fractured. The location and severity of the injuries suggest that he was down on his left knee and was manipulating the weapon with both hands at the moment of detonation. We consider that 66 mm M72 HEAT rocket accidentally detonated during his handling. Very rarely are civilians killed by a military weapon, except during wartime. Appropriate investigation of various explosive injuries provide not only evidence of the cause of death, but also the position and posture of the body.

Suicidal hanging: Fatalities in Istanbul Retrospective analysis of 761 autopsy cases

We retrospectively analyzed the autopsy records of the Institute of Forensic Medicine during the five-year period between 1998 and 2002 to document the characteristics of fatalities resulting from hanging which is the commonest mode of suicide in Istanbul. Upon analysis of death scene investigation and autopsy reports together with the information gathered from the police, the cases of hanging fatalities of suicidal origin were selected. Seven hundred sixty one hanging cases of suicidal origin were detected and evaluated in terms of demographic features, the type of hanging material used for ligature, cause of death, internal findings in neck organs, other traumatic findings suggesting the use of another method for suicide, toxicological findings and microscopic findings in delayed death cases. In 364 of these cases suspension was complete and in 397 incomplete. Five hundred thirty seven of those (70.56%) were male and 224 (29.44%) were female. The preponderance of male cases in our autopsy population was also detected in suicidal hanging cases. There was no case aged lower 10 and the number of the cases in the age group of cases aged over 80 was the lowest (n=3, 0.4%). In 634 of cases, the place of hanging was the subject's own house, most victims selected rope (652 cases) for the ligature with the rest using sheet, belt, cable and necktie. There were traumatic findings showing attempts of suicide other than hanging in 24 cases (tentative marks in 22 cases and non-fatal burning in 2). In 23 of cases, there were bruises of different ages. In these cases females constituted the majority suggesting violence against women that is a social problem in various cultural subgroups of our country. This violence may have played a role in the decision of suicide. Superficial bruises were detected in 56 cases and were attributed to the trauma. Fractures in neck organs were detected in 446 of cases. In fracture-determined cases, fracture in hyoid bone was seen in 177, in thyroid cartilage in 163, in both hyoid and thyroid in 106. Vertebral fracture was detected in six cases and fractures both in hyoid, thyroid and vertebra was found in four cases. Hyperemic lines around the ligature were prominent in 620 of the cases and soft tissue ecchymoses in all cases. In 305 of the cases (40.07%) diagnosis was based only on the soft tissue hemorrhage.

Multiple myeloma involving the thyroid cartilage

Multiple myeloma, solitary plasmacytoma, and extramedullary plasmacytoma constitute a continuous disease spectrum of plasma cell neoplasms. In the larynx, although extramedullary plasmacytoma in the supraglottic region has been sometimes reported, plasma cell neoplasm with involvement of the thyroid cartilage is extremely rare. We report a case of multiple myeloma involving the thyroid cartilage. A 72-year-old male patient presented with a pathological fracture of the cervical vertebrae. CT scan revealed low-density areas within the thyroid cartilage, but the laryngeal mucosa and submucosal soft tissue were intact. Multiple myeloma was diagnosed, since the tumors in the thyroid cartilage and cervical vertebrae revealed plasmacytoma. Because no other lesion was found, irradiation of the larynx and cervical vertebrae was performed. Neither aggressive change of these lesions nor new lesions have been found over 3-year follow-up following the initial treatment without adjuvant therapy.

The role of thyroplasty in the management of sulcus vocalis

OBJECTIVES

The results of objective and subjective evaluation of postoperative vocal function were assessed in patients treated with thyroplasty for the correction of sulcus vocalis.

PATIENTS AND METHODS

Six patients (5 males, 1 female; mean age 26 years; range 18 to 34 years) underwent thyroplasty for sulcus vocalis. Voice evaluations were performed one week before and two months after surgery. None of the patients had voice therapy before evaluations in the postoperative period. The mean follow-up period was 14.8 months.

RESULTS

Compared to the preoperative values, postoperative voice handicap index scores were significantly different (p=0.002). However, the difference between the dysphonia severity index (DSI) scores were not significant (p=0.810).

CONCLUSION

A subjective rather than an objective improvement was observed in voice. Our results suggest that, in the evaluation of voice patients, therapeutic success should not be based only on objective criteria, but subjective criteria should also be considered.

Cricothyroidotomy: a short-term measure for elective ventilation in a patient with challenging neck anatomy

Cricothyroidotomy is a well established technique of airway management in emergency situations where translaryngeal intubation cannot be achieved. This case report describes a case where cricothyroidotomy was used for elective ventilation for short period of 48 hours in a patient who had a vocal cord palsy, supraglottic oedema and inflammation. Surgical tracheostomy was considered the preferred option, but this was deemed impossible due to the challenging neck anatomy in this case.

Surgical anatomy of the recurrent laryngeal nerve revisited

OBJECTIVES

Previous anatomic studies of the recurrent laryngeal nerves (RLNs) have described the variability in the course of the RLN. The anatomy of the nerve appears more constant along its distal segment near the cricothyroid joint, which is our surgical approach to the initial identification of the nerve. Understanding the topographical anatomy of the nerve in this region facilitates quick and safe nerve identification. The surgical topographical anatomy of the nerve in this region has not been studied in detail, which is the focus of this study.

METHODS

A total of 278 RLNs in 190 patients were dissected during thyroidectomy and/or parathyroidectomy. The course of the nerve was recorded, paying particular attention to the directional course along its distal portion. The angle in which it coursed in relationship to a line paralleling the tracheoesophageal groove was determined.

RESULTS

All 278 nerves were identified. Seventy-eight percent of the right-sided nerves coursed between 15 and 45 degrees, and 77% of the left-sided nerves coursed between 0 and 30 degrees. It appears that the nerve is more likely to travel at a more obtuse angle with right-sided RLNs and in patients with a low-lying cricoid. There was no permanent postoperative RLN palsy, and the incidence of temporary palsy was 1%.

CONCLUSIONS

Approaching the nerve along its distal portion is safe and effective. The surgical topographical anatomy in this region is described in detail. Some of the potential advantages of identifying the nerve more distally include less chance of disrupting the blood supply to the inferior parathyroid gland, dissection along a shorter portion of the nerve, and less variability of the nerve.

[Prostate cancer metastasized to thyroid cartilage: a case report]

A 75-year-old male was diagnosed as prostate cancer (serum PSA: 4,772 ng/ml, Gleason score: 4 + 4 = 8) with multiple bone metastases. And he noticed a painless mass of the frontal neck a month before the diagnosis. Computed tomography of the neck showed a tumor in the thyroid cartilage. Biopsy of the neck tumor revealed metastasis of prostate cancer by positive PSA staining. Metastasis of malignant tumor to cartilaginous tissue is extremely rare because there are usually no vessels in it. Only 4 cases of the metastasis of prostate cancer to the thyroid cartilage have been reported. It was thought that tiny bone marrows were formed in the ossified cartilage and it caused hematogenous metastasis.

[Comparative study of the parameters related to type I thyroplasty measured by laryngeal specimens and computed tomography]

OBJECTIVE

To determine the consistence of the parameters related to type I thyroplasty measured by laryngeal specimens and CT scan.

METHODS

The related parameters of 50 laryngeal specimens (unilateral) obtained following total laryngectomy were measured postoperative immediately, and compared with those measured by spiral CT scan with multiple plain reconstructive (MPR) technique preoperatively. Comparative results were analyzed to evaluate the statistical significance between these two methods.

RESULTS

There were no significant statistical differences among the 6 parameters between two methods (P > 0.05), and the results (x +/- s) measured by CT scan and laryngeal specimens showed that the length of the thyroid notch to the inferior thyroid border were (20.7 +/- 1.7) mm and (20.6 +/- 1.7) mm; the length of the vocal cord were (17.3 +/- 1.8) mm and (17.3 +/- 1.8) mm; the length of the oblique line were (28.6 +/- 3.2) mm and (29.1 +/- 2.7) mm; the length of the presumptive horizontal line were (26.2 +/- 2.0) mm and (26.2 +/- 2.0) mm; the endolaryngeal vertical length of the anterior of the vocal cord to the presumptive horizontal line were (4.5 +/- 0.6) mm and (4.5 +/- 0.7) mm; the endolaryngeal vertical length of the vocal process to the presumptive horizontal line were (10.8 +/- 1.1) mm and (10.9 +/- 1.1) mm, respectively. As a result, the endolaryngeal anterior and posterior width of the wedge inserted in the thyroid cartilage were 4 - 5 mm and 8 - 9 mm respectively.

CONCLUSIONS

MPR technique of spiral CT scan is able to design the size of the window and the prosthesis of type I thyroplasty preoperatively, which was testified to be a precise and reliable method to measure the larynx.

Ossification of laryngeal cartilages on lateral cephalometric radiographs

This study was undertaken to identify the variations in the physiologic ossification of human laryngeal cartilages by evaluating the lateral cephalometric radiographs of healthy males and females referred to our facility. Lateral cephalometric radiographs of 359 patients (141 male and 218 female; ages 10 to 59 years) referred from various specialty clinics between April 1998 and March 2000 were used. Frequencies and confidence intervals were obtained and tabulated for both thyroid and cricoid ossifications as seen on these cephalometric radiographs. The interobserver agreement was strong for both thyroid (kappa = .986) and cricoid (kappa = .982) observations. Overall, thyroid cartilage was more frequently ossified compared with cricoid. Various degrees of thyroid and cricoid cartilage ossification were found in 186 patients (120 female and 66 male) in the third decade and beyond. Among 173 patients in the first 2 decades (98 females and 75 male), evidence of thyroid ossification was found in 2 male patients aged 14 and 18, and ossification was detected in the cricoid cartilage in 12 patients. There was a preponderance of laryngeal cartilage ossification in men compared with women. Radiographically detectable laryngeal ossification increased with age starting in the third decade. There is a general trend of increase in the ossification of laryngeal cartilages as the age advanced.

Perichondrial flap to prevent chondritis and cartilage necrosis in salvage vertical partial laryngectomy for recurrent glottic carcinoma after irradiation: a new procedure

CONCLUSION

We conclude that our new closure method using the posterior- and inferior-based perichondrial flap may diminish the chance of development of chondritis in salvage vertical partial laryngectomized patients with recurrent glottic cancer.

OBJECTIVE

Post-radiation laryngeal chondritis with resultant cartilage necrosis is one of the most dreaded complications of radiotherapy treatment of glottic carcinoma. In the case of salvage vertical partial laryngectomy, the risk of its development may be increased. We introduce a new posterior- and inferior-based perichondrial flap procedure to prevent postoperative chondritis after salvage vertical partial laryngectomy.

MATERIAL AND METHODS

The perichondrium is incised along the midline and upper border of the thyroid cartilage, but not along the inferior border, unlike the conventional method. Then, the posterior- and inferior-based perichondrial flap, along with the cricothyroid muscle fascia, is elevated from the midline. For closure of the pharyngeal lumen, the outer perichondrium of the lesion side is sutured to the inner perichondrium of the contralateral side to protect the larynx from pharyngeal secretion. The utility of this procedure is reviewed retrospectively in 10 patients with locally persistent or recurrent squamous cell carcinoma of the vocal cord after failed laryngeal radiation therapy between 1994 and 2001.

RESULTS

None of our patients developed chondritis postoperatively. The interval between the operation and removal of the tracheostomy tube ranged from 8 to 23 days (mean 12 days). Patients were able to swallow without aspiration within 7-22 days of the operation (mean 10 days). Discharge from hospital was possible after a mean recovery period of 11 postoperative days.

Prognostic factors of glottic carcinomas treated with radiation therapy: value of the adjacent sign on radiological examinations in the sixth edition of the UICC TNM staging system

PURPOSE

To evaluate the predictive value of the adjacent sign, the tumor adjacent to the thyroid cartilage on radiologic examinations, in the new sixth edition of the International Union Against Cancer (UICC) staging system of glottic carcinoma.

METHODS AND MATERIALS

Between 1989 and 1998, 130 patients with T1-2N0 glottic squamous cell carcinoma, classified according to the fifth edition of the UICC staging system and evaluated by computed tomography or magnetic resonance imaging, were treated with radiation therapy (RT). Factor analysis included clinical, radiologic, and treatment characteristics. Tumors with the adjacent sign, considered representative of paraglottic space invasion with or without minor thyroid cartilage erosion, were retrospectively classified as T3-stage tumors by the UICC sixth edition.

RESULTS

The 5-year local control rate after RT was 76%. Univariate analysis showed that the T stage according to the UICC fifth edition, supraglottic extension, subglottic extension, tumor size, adjacent sign, total dose, fraction size, field size, and overall treatment time were significant factors for the local control rate. Multivariate analysis confirmed the adjacent sign as the only independent predictor. According to the UICC sixth edition, the 5-year local control, laryngeal preservation, cause-specific survival, and overall survival rates of the T3 (adjacent sign-positive) vs. T1 and T2 (adjacent sign-negative) lesions were 37% vs. 87% (p < 0.0001), 47% vs. 95% (p < 0.0001), 75% vs. 99% (p < 0.0001), and 54% vs. 81% (p = 0.0180), respectively.

CONCLUSION

Factor analysis confirmed the adjacent sign as an independent prognostic factor. The UICC sixth edition appears to identify correctly patients with T3 lesions as a high-risk group.

[Pseudohypertrophy of the ventricular bands due to deformation of the thyroid cartilage]

Hoarseness due to phonation by the false cords (dysphonia plicae ventricularis) is a common cause of functional dysphonia, in relation to excessive muscular tension in the larynx area. Nevertheless, a mechanic cause can be observed in some cases with dysphonia plicae ventricularis, which is usually due to deformation of the thyroid cartilage. We report a case with hypertrophy of the ventricular bands which was treated by vocal rehabilitation followed by suspension laryngoscopy with partial removal of the ventricular bands, without further improvement. This failure was related to a pseudohypertrophy of the ventricular bands, due to deformation of the thyroid cartilage, which was confirmed by computed tomography.

Prognostic evaluation in supracricoid partial laryngectomy with cricohyoidopexy

Identification of prognostic factors related to supracricoid partial laryngectomy may optimise indications for this surgical technique. We analysed several clinical and histopathological variables in a series of 81 patients treated with SPL at our department. Attention was focused on neoplastic spread of the anterior commissure, thyroid cartilage and prelaryngeal soft tissue of the neck. Statistical analysis (Kaplan-Meier method and Cox regression test) showed a significant decrease in survival for prelaryngeal soft tissue invasion. Due to the fact that the survival rate is not modified by the anterior commissure and thyroid cartilage infiltration, the prognostic value of prelaryngeal invasion is extremely relevant. Therefore, we suggest the oncological value of SPL even in cases of invasion of the anterior commissure or thyroid cartilage, but not beyond the outer perichondrium.

Lateral thyrotomy with strap muscle transposition for Teflon granuloma

Lateral thyrotomy and strap muscle transposition have been used independently before. However, the published literature does not record the coordinated use of both procedures in the treatment of Teflon granuloma. In this paper, we present a case of vocal fold paralysis that had been treated successfully by Teflon injection in 1999. Two years later, however, the patient developed a host of symptoms that included a husky voice, shortness of breath and suffocation, which indicated Teflon granuloma. He underwent surgery to excise the Teflon granuloma via a lateral thyrotomy. The affected paraglottic space was then reconstructed using strap muscle transposition. One year postoperatively, the glottis had closed completely on phonation, and the voice retained a moderate roughness due to a scarring change from the earlier Teflon reaction. The patient had no problems with aspiration or shortness of breath during speaking. Our experience indicates that a physician can remove the entire granuloma and create a smooth, straight vibratory surface with complete glottic closure during phonation by using a combination of lateral thyrotomy and strap muscle transposition.

Dedifferentiated chondrosarcoma of the larynx

Dedifferentiated chondrosarcoma is an uncommon malignant cartilaginous neoplasm of bone characterized by the presence of a malignant spindle cell neoplasm associated with a low- or medium-grade chondrosarcoma. Origin of this tumor in the cartilagenous framework of the larynx is very rare. A 60-year-old male with a 2-year history of hoarseness and dyspnea was examined while presenting in acute airway distress. Direct laryngoscopy revealed a mass of the right side of the larynx. Histopathologic examination revealed a malignant cartilaginous tumor with a malignant spindle cell component. We report a case of dedifferentiated chondrosarcoma arising in the thyroid cartilage. This, to our knowledge, is the eleventh fully documented case of this neoplasm arising in the larynx.

Decreased Local Control Following Radiation Therapy Alone in Early-Stage Glottic Carcinoma with Anterior Commissure Extension*

PURPOSE

To assess the patterns of failure in the treatment of early-stage squamous cell carcinoma of the glottic larynx.

PATIENTS AND METHODS

Between 1983-2000, 122 consecutive patients treated for early laryngeal cancer (UICC T1N0 and T2N0) by radical radiation therapy (RT) were retrospectively studied. Male-to-female ratio was 106 : 16, and median age 62 years (35-92 years). There were 68 patients with T1a, 18 with T1b, and 36 with T2 tumors. Diagnosis was made by biopsy in 104 patients, and by laser vaporization or stripping in 18. Treatment planning consisted of three-dimensional (3-D) conformal RT in 49 (40%) patients including nine patients irradiated using arytenoid protection. A median dose of 70 Gy (60-74 Gy) was given (2 Gy/fraction) over a median period of 46 days (21-79 days). Median follow-up period was 85 months.

RESULTS

The 5-year overall, cancer-specific, and disease-free survival amounted to 80%, 94%, and 70%, respectively. 5-year local control was 83%. Median time to local recurrence in 19 patients was 13 months (5-58 months). Salvage treatment consisted of surgery in 17 patients (one patient refused salvage and one was inoperable; total laryngectomy in eleven, and partial laryngectomy or cordectomy in six patients). Six patients died because of laryngeal cancer. Univariate analyses revealed that prognostic factors negatively influencing local control were anterior commissure extension, arytenoid protection, and total RT dose < 66 Gy. Among the factors analyzed, multivariate analysis (Cox model) demonstrated that anterior commissure extension, arytenoid protection, and male gender were the worst independent prognostic factors in terms of local control.

CONCLUSION

For early-stage laryngeal cancer, outcome after RT is excellent. In case of anterior commissure extension, surgery or higher RT doses are warranted. Because of a high relapse risk, arytenoid protection should not be attempted.

Homicidal and suicidal ligature strangulation—a comparison of the post-mortem findings

Suicides by ligature strangulation are rare events. In Berlin (3.5 million inhabitants; ca. 500 suicides per year) approximately one case per year occurs. Here, we present the main findings of 19 cases investigated between 1978 and 1998, compared to 47 cases of homicidal ligature strangulation. Two of the 19 suicidal victims had single fractures of the upper thyroid horns and one victim a fracture of a lower thyroid horn; other types of laryngohyoid injuries were not observed. In the homicidal series, the laryngohyoid structures were unaffected in 26 cases (12 of these victims were children or adolescents), single thyroid horn fractures were present in three cases and more significant injuries in 18 cases. Macroscopic bleedings of the laryngeal muscles were found in 12 victims of the homicidal group and in none of the suicidal. Bleedings in the neck muscles seldom occurred in suicides. According to these findings, the laryngohyoid injuries can be helpful in the differentiation of suicide from homicide, if more than a single thyroid horn fracture or a laryngeal soft tissue trauma is present.

Pitfalls in the diagnosis and management of laryngeal chondrosarcoma

Chondrosarcomas of the larynx (CS) are uncommon and predominantly affect the cricoid cartilage. In the larynx they have a distinctive biological behaviour and require individual treatment. A retrospective study was made on three cases of CS, all presenting with compromise of the upper respiratory tract. The medical history varied from several weeks to six years. Correct diagnosis required open resection of the lesion in all cases. Due to intra-operative findings, all patients underwent total laryngectomy. CS grow slowly and are therefore frequently diagnosed late in the course of the disease. A subglottic bulging of the mucosa should indicate high-resolution-computed-tomography of the larynx to exclude affection of the laryngeal framework. Correct diagnosis of laryngeal cartilaginous tumours requires a complete examination of the entirely resected tumour. Only extended and de-differentiated CS indicate further radical surgery, the remainder call for conservative surgical management.

Laryngotracheal involvement of relapsing polychondritis in a Korean girl

We describe a young girl presenting with acute dyspnea because of laryngotracheal involvement of relapsing polychondritis (RP). RP, a multisystemic disorder of unknown etiology, is a very rare disease in children. It is characterized by inflammation and destruction of the cartilaginous structure of many organs, including the respiratory tract. Early respiratory tract involvement in younger patients is the greatest threat to life, and aggressive therapy, including tracheostomy and intravenous high-dose steroids, is advocated.

Experimental investigations of fractures of the upper thyroid horns

Fractures of the upper thyroid horns are a frequent finding after a variety of neck injuries - resulting from a direct mechanical trauma, e.g. compression of the neck in manual strangulation or ligature strangulation, from blunt injuries (falls or blows against the neck), and sometimes from indirect trauma (whiplash-injuries). Although it is well known that thyroid horns can be broken with relatively little pressure, no quantitative data are available in the literature. In an experimental investigation, the isolated thyroid cartilage was prepared (divided into two parts, measured, X-rayed, photographed, embedded in paraplast) and clamped in a simple apparatus. Weight was applied on the upper thyroid horn (imitating pressure on the horns), beginning with 1 kg and gradually increased by increments of 250 g to a maximum of 8 kg, until an 'injury' occurred. In this study, 120 thyroid cartilages (77 men, 43 women, 16-95 years) were investigated. The location of the fractures was in nearly all cases the base of the horns. The mean weight resulting in an injury of the horn was 3 kg (men: 3.3 kg, women: 2.6 kg). The required weight was dependent on the degree of ossification. The highest rate of fractures was found in cases with incomplete ossification; in cases without ossification, specimens often remained macroscopically uninjured.

A case report of difficult diagnosis in the patient with advanced laryngeal tuberculosis

We report a patient with severe laryngeal tuberculosis (LTB) involving thyroid cartilage and combined with whole-bone metastasis. A 57-year-old male had presented only with hoarseness. Radiological findings were indicative of suspected metastasis from a malignant tumor. However, tuberculosis was considered by histopathological findings, and so sputum samples were tested for acid-fast bacilli and purified protein derivatives of tuberculin in order to detect the presence of LTB. A polymerase chain reaction confirmed the diagnosis. Anti-tuberculous medications were effective in resolving the hoarseness, and the removal of the mass in the right wing of thyroid cartilage was confirmed by computed tomography (CT).