Isolated laryngeal lymphangioma: a rare cause of airway obstruction in infants

Laryngeal lymphangiomas are uncommon and virtually always represent extension of cervical disease. The exceptionally rare lymphangioma that remains isolated to the larynx has been reported only twice prior to this case. A six-month male infant presented with an undiagnosed mass in the supraglottis which had caused respiratory compromise requiring a tracheostomy. The diagnosis was made histologically and the treatment was begun. Therapy consisted of staged laser resections carried out cautiously to preserve laryngeal competence. After three laser treatments the lesion was controlled and the patient prepared for decannulation. This interesting case is presented with a review of the literature.

Methotrexate removal during haemodialysis in a patient with advanced laryngeal carcinoma

A 62-year-old patient on long-term haemodialysis who developed an inoperable T2N3Mo squamous-cell carcinoma of the larynx was treated with weekly low-dose methotrexate (MTX) after failing to respond to radiotherapy. The patient was initially given one dose of 10 mg MTX (6 mg/m2) as a 1-h infusion, then he received three further i.v. doses of 20 mg (12 mg/m2). Haemodialysis was performed 15-18 h after each dose and the patient received folinic acid (30 mg i.v.q 6 h) until the MTX concentration was < 0.1 mumol/l. The MTX concentration was measured regularly until it reached < 0.1 mumol/l, and additional samples were withdrawn pre- and post-dialysis. The MTX elimination rate constant and half-life were estimated with the patient on and off dialysis. The patient failed to respond to treatment but did not experience MTX-related toxicity. The elimination half-life ranged from 22 to 42 h when he was off dialysis but fell to a median of 5.5 h during dialysis. Low-dose MTX was given to a patient on regular haemodialysis without evidence of toxicity. The rate of MTX elimination was increased during haemodialysis, although high MTX concentrations persisted for several days and prolonged rescue with folinic acid was required.

Histopathological and immunohistochemical studies of acquired tracheobronchomalacia: an autopsy case report

A 72-year-old patient was reported to have 'saber-sheath-type' acquired tracheobronchomalacia after irradiation therapy for laryngeal cancer. The pathogenetic features of this case were demonstrated immunohistopathologically using CD68, HLA-DR, UCHL1, L26 and Ki-67 antibodies. The principal features were (a) selective destruction of the cartilage with Ki-67 stainability from the trachea to the segmental bronchi with inflammatory infiltrations of predominant T lymphocytes (UCHL1-positive) and activated macrophages (CD68-positive with marked HLA class II antigen) and (b) replacement by collagen fibers through the affected lesion. The tissues, except for the cartilage in the airway tract, were preserved without marked change, including the membranous portion. The cartilage at organs other than the airway showed no changes. We first clarified the immunohistopathology of tracheobronchomalacia. We proposed that the characteristic cell-mediated immunity against cartilage with T lymphocytes and activated macrophages in the pathogenetic features may be related to a cancer-healing tendency.

Squamous cell carcinoma of the pharynx and larynx presenting as a neck abscess or cellulitis

Head and neck tumours presenting as a neck abscess or cellulitis are extremely rare. We report two cases of supraglottic squamous cell carcinoma which presented as an abscess in the site of metastatic neck nodes, one of which was occult and a third case of squamous cell carcinoma of the pyriform fossa which presented as cervical cellulitis. Biopsy of the abscess wall at the time of drainage and careful follow-up may lead to an earlier diagnosis of occult carcinoma.

[Congenital subfold hemangioma in combination with hemangiomatosis of the head, face and neck]

The treatment was made of 15 children aged 3-6 months with advanced hemangiomatosis of the head, face, neck and larynx. The treatment combined hormone therapy, sclerotherapy of the tumor, staged cryodestruction of the external and endolaryngeal nodes. In one case the arterial occlusion was performed. Good cosmetic results and recovery of adequate respiration were achieved in 13 children.

Laryngeal chondroma: a benign process with long-term clinical implications

Chondroma of the laryngeal cartilage is a rare, benign neoplasm which can manifest as a neck mass or, if situated within the airway, as slowly progressive obstruction, hoarseness or dyspnea. The most common location for chondroma is the posterior lamina of the cricoid cartilage; the next most common locations are the thyroid, arytenoid and epiglottic cartilages. Chondroma and low-grade chondrosarcoma are difficult to distinguish from one another histologically. Although chondrosarcoma reportedly recurs, local surgical excision without radical margins and with long-term clinical follow-up is recommended. We report one case of thyroid cartilage chondroma and include a review of radiologic studies and histopathologic analysis results. We also report a second case with severe airway obstruction caused by a large cricoid chondroma. A review of the English language biomedical literature on laryngeal chondroma is included.

Intensive care unit stay is prolonged in chronic alcoholic men following tumor resection of the upper digestive tract

BACKGROUND

The prevalence of chronic alcohol misuse in patients with oral, pharyngeal, laryngeal or esophageal carcinomas exceeds 60%. No data is available, to our knowledge, on the morbidity and mortality of chronic alcoholics in surgical intensive care units (ICU) following tumor resection. We investigated whether the subsequent ICU stay in chronic alcoholics following tumor resection was prolonged and whether the incidence of pneumonia and sepsis was increased.

METHODS

213 patients with carcinomas of the upper digestive tract were evaluated regarding their drinking habits. Chronic alcoholics met either the DSM-III-R criteria for alcohol abuse or dependence. Conventional laboratory markers and serum carbohydrate-deficient transferrin were determined preoperatively. Major intercurrent complications during ICU stay such as an alcohol withdrawal syndrome, pneumonia and sepsis as well as the frequency of death were documented.

RESULTS

Patients did not differ significantly between groups regarding age or APACHE score on admission to the ICU.121 patients were diagnosed as being chronic alcoholics, 39 as being social drinkers and 61 as being non-alcoholics. In chronic alcoholics the frequency of death was significantly increased. Due to the increased incidence of pneumonia and sepsis the ICU stay was significantly prolonged in chronic alcoholics by approximately 8 days.

CONCLUSIONS

The increased mortality and morbidity rate demonstrates that chronic alcoholics undergoing major tumor surgery have to be considered as high-risk patients during their postoperative ICU stay. Further studies are required with respect to the immuno-competence of chronic alcoholics and the prevention of alcohol withdrawal syndrome, pneumonia and sepsis in these patients.

Isolated non-Hodgkin's malignant lymphoma of the larynx presenting as a large pedunculated tumor

This paper presents a case of non-Hodgkin's lymphoma (NHL) of the larynx. The patient was an 86-year-old man who complained of foreign-body sensation and dysphagia. Laryngoendoscopic examination revealed a large pedunculated mass arising from the left aryepiglottic fold. A diffuse, large, B-cell-type NHL was diagnosed histopathologically. The patient was treated with combination chemotherapy, resulting in complete clinical remission. The clinicopathological features of this case have been described and compared with previously reported cases.

Upper airway obstruction in a woman with AIDS-related laryngeal Kaposi's sarcoma

Kaposi's sarcoma rarely causes upper airway obstruction. In the only two previously reported cases, both patients were men who died of hemorrhage shortly after tracheostomy. We describe a 45-year-old woman with AIDS who presented with stridor secondary to Kaposi's sarcoma of the larynx. To our knowledge, this is the first report of this presentation in a woman and the first reported patient with Kaposi's sarcoma to survive tracheostomy.

["Near-total" laryngectomy: functional results]

"Near total" laryngectomy is an alternative to total laryngectomy in some advanced laryngeal tumors. A prospective study was made of the results obtained in 40 patients treated with near total laryngectomy. Speech was achieved in 74.3% of patients within a mean time interval of 63 days. Of the subjects who had more than 5 months of follow-up, 84.6% could speak. Half of the patients who achieved speech used the Barton-Mayo button and did not need to use their hand for phonation. Major swallowing problems were found in 13.9%. The most common complication was pharyngo-cutaneous fistula (58.9%).

Steroids for intubated croup masking airway haemangioma

Recently, the beneficial role of steroids for acute laryngotracheobronchitis has been more clearly defined for both intubated and unintubated patients. However, corticosteroids also improve the clinical signs of airway haemangiomata. Two patients are described who illustrate how this can be a source of diagnostic confusion.

An unusual reason for obstructive sleep apnea in a boy with hemophilia B: supraglottic papilloma

An unusual cause of obstructive sleep apnea in a boy with hemophilia B who was urgently intubated during the night because of suspected bleeding into the airway is analysed. The cause of airway obstruction was a floating papilloma hanging from false cord. At inspirium the tumor was moving immediately above the vocal cords. This was manifested during sleep by noisy snoring and numerous apneic pauses. When the child was awake he had no respiratory problems. After the tumor was removed, the boy breathed freely during sleep. However, the papillomas recur in various parts of the larynx and repeated surgical treatment by factor IX replacement: therapy is necessary.

[Radiotherapy of T1N0 neoplasms of the glottis. Analysis of the parameters that influence local control]

Treatment and tumor-related parameters were reviewed in 176 patients with T1N0 carcinoma of the glottic larynx submitted to primary radiation therapy from 1980 to 1992. Our aim was to analyze local control and treatment-related toxicity. Over-all local control rates at 10 years were 88.3% with irradiation alone and 94.5% after salvage surgery (larynx preservation: 91%). Verrucous histology was a negative factor affecting local control and anterior commissure involvement exhibited only a negative trend but had no statistical significance. Among treatment-related factors, local control was 76.5% after split-course and 91.1% after continuous-course irradiation (p < 0.05). With continuous-course irradiation, the total dose influenced local control only for single of 2 Gy (local control rates were 69% with 60 Gy and 93% at > or = 64 Gy; p < 0.05), but not for single doses of 2.25 Gy and total doses ranging 56.25-65.25 Gy (local control failed in 55 patients). Early and late complications did not increase with single doses > or = 2.25 Gy. Our current policy in T1N0 nonverrucous glottic carcinoma is to use a single fraction of 2.25 Gy and a total dose ranging 56.25-63 Gy according to tumor size, with a continuous course.

[Respiratory insufficiency caused by a vocal cord polyp. An accidental finding during respiratory function tests]

We present a case in which a 58-year-old woman was admitted for spirometry due to progressive dyspnoea. She had a history of chronic obstructive pulmonary disease treated for more than 20 years. The flow-volume loop indicated an upper airway obstruction. An otolaryngologic examination revealed a vocal cord polyp. It was excised and the patient's dyspnoea was relieved. The following spirometry indicated that the upper airway obstruction had been removed. The aim of this case report is to demonstrate that the flow-volume loop is a useful method in diagnosing and quantifying upper airway obstructions.

[Hoarseness]

Hoarseness is a cardinal symptom of laryngeal disease. It is a disturbance of the normal voice pitch that can be evaluated acoustically using the 'RBH scale' [R for roughness, B for breathiness, H for hoarseness]. Hoarseness lasting longer than three weeks or recurring must be evaluated by an ENT specialist or a phoniatrist. Causes of hoarseness include functional disorders of the voice, inflammation of the larynx, secondary changes of the vocal folds, polyps, cysts, edema, papillomas, tumors, trauma, or palsies of the vocal cords due to different reasons. Early diagnosis of malignant laryngeal tumors is a prerequisite for preserving voice quality. Functional disorders and unilateral palsies of the vocal folds are treated by logopedists. The therapy of choice for inflammations is relief of symptoms, and surgery is employed for organic lesions.

Investigation of heart rate variability in a dog with upper respiratory tract obstruction

An eight-year-old bull mastiff presented with respiratory obstruction caused by a tumour dorsolateral to the larynx. Removal of the tumour was attempted but the dog died. A novel noninvasive measurement of heart rate variability and cardiac parasympathetic activity, recorded real-time from an electrocardiograph signal, was used to investigate cardiac rhythm in the dog. A simultaneous record of heart rate and cardiac parasympathetic activity showed severe sinus arrhythmia caused by the parasympathetic tone, in which the inspiratory heart rate exceeded 140 beats per minute (bpm) and the expiratory heart rate fell to below 60 bpm. The extent of respiratory modulation of the cardiac parasympathetic activity (vagal tone) has not been reported before using this technique on-line in a conscious, freely-behaving and spontaneously breathing animal. Non-invasive measurements of cardiac parasympathetic tone show great potential for the assessment of animals with systemic and cardiac disease including cardiac failure.

Airway obstruction. The problem and its causes

Chronic airway obstruction usually has an insidious onset. It is often difficult to diagnose unless the patient is examined by a physician familiar with the problem and causes. Potential causes can be divided into infectious, inflammatory, traumatic, and neoplastic. Although the precise incidence of each category is unknown, trauma, secondary to previous prolonged intubation for mechanical ventilation, is currently the most common premorbid factor.