Laryngeal inflammatory myofibroblastic tumor

Inflammatory myofibroblastic tumor seldom involves the larynx, as only about 50 to 60 cases have been described in the literature. Even though these tumors are often not aggressive, they have the potential for invasion and local recurrence. We describe the case of a 27-year-old man who was admitted to an emergency department with signs of upper airway obstruction secondary to an obstructive mass. Histology identified the mass as an inflammatory myofibroblastic tumor of the subglottis. The patient underwent an emergency tracheotomy followed by a partial laryngectomy. During 14 months of follow-up, he remained free of active disease.

Typical laryngeal carcinoid tumor with recurrence and lymph node metastasis: a case report and review of the literature

Typical carcinoid tumor of the larynx is an extremely rare lesion which arises from neuroendocrine cells scanning in the laryngeal mucosa or submucosal glands. Conventionally, it is a well-differentiated neuroendocrine carcinoma, conservative surgery represents the treatment of choice, and the patient usually has a good prognosis with rarely recurrence and metastasis. In this report, we present a case of typical laryngeal carcinoid tumor with recurrence and lymph node metastasis. The patient was a 58-year-old man, complaints of intermittent burning pain in his both ears for 2 years, and for the recent one month the pain turn to continuous accompanied with a mild discomfort in the throat, he had neither hoarseness, dysphagia, nor any otorrhea and hearing loss. The patient was scheduled to undergo a tracheotomy and then a biopsy under supporting laryngoscopy. During the operation, the frozen section diagnosis from the first and the second time both indicated that the biopsy specimens originated from musculo-epithelia, it couldn't be differed from malignant to benign. So the mass was simply removed under supporting laryngoscopy. The histopathology from paraffin sections revealed typical carcinoid of the larynx and the second procedure consisted of supraglottic laryngectomy with clear margins, the otalgia resolved and the patient had no difficulty with phonation or swallowing. After 1 year follow-up, the patient was found a mass on his right neck with symptom free, B-ultrasonography indicated several enlargement lymph nodes with some merged on both sides of the neck, the patient was scheduled to undergo a "total-laryngectomy with radical neck dissection on the left side and an elective neck dissection on the right side". The specimens were positive for cytokeratin, chromogranin A and synaptophysin, a final diagnosis of typical carcinoid was made for the recurrence lesion and the metastasis of the lymph nodes. Though the post-operative recovery was uneventful, the prognosis was not good, the patient died six months later. Here, we review the pertinent references on this subject, and discuss the main managements for typical carcinoid tumor of the larynx.

[1 case of vocal cord plexiform schwannoma]

Summary A 36 years old patient with hoarseness for 2 years and got worsen for one month, electronic laryngoscopy showed a red smooth-faced wide based neoplasm on the posterior 2/3 of the right side of the vocal cords. The neoplasm was excised under suspension laryngoscope . The pathologic results showed:Cells were weave patterned, infiltrative growth, mitotic figure was rare. Immunohistochemical results showed CD34 (-), SMA (-), DM (-), S - 100 (+). The pathological diagnosis was plexiform schwannoma.

[Objective evaluation of CO2 laser in the treatment of Tis--T glottic carcinoma after operation for voice rehabilitation]

OBJECTIVE

To objectively evaluate the voice rehabilitation status in different period after treatment of Tis--T1 glottic carcinoma by CO2 laser with voice parameters.

METHOD

A retrospective review of 41 cases with Tis--T1 glottic carcinoma treated by CO2 laser was performed, 23 cases were stage Tis (Tis group) and 18 cases with stage T1N0M0 (T1 group). The range of excision of the lesion by CO2 laser was according to the different stages of the tumor, and ensured theoperation negative margin was by intraoperative frozen pathological examination. We tested and compared the actual voice (coritaine F0, Jitter, Shimmer, NNE and MPT) of 30 cases of healthy middle-aged and old male(normal group) and all the patients at one day prior to operation, three months, six months and one year after operation respectively, which was to evaluate the voice rehabilitation status in different period after operation objectively.

RESULT

Postoperative pathological examination revealed, 23 cases were squamous epithelium severe atypical hyperplasia, 16 cases were well differentiated squamous cell carcinoma, and 2 cases were moderately differentiated squamous cell carcinoma. Palatoglossal arch mucosal tear occurred in 3 patients. Respiratory difficulties were not seen in all cases, and normal oral feeding was obtained in all cases in postoperative three days. All patients were followed up for one year. There was statistical significance in F0, Jitter, Shimmer of both Tis group and T1 group after operation in different periods(P<0.05). But there was no statistical significance in NNE and MPT between six months and one years after operation in the two groups(P>0.05).

CONCLUSION

CO2 laser surgery is an effective treatment for early glottic carcinoma. Postoperative vocal function was improved in varying degrees, and voice quality gradually improved with the rehabilitation time. Partly objective parameters reflecting the vocal function gradually stabilized after half a year after operation.

[A case of synchronous triple cancer treated with multidisciplinary therapy - cancers in the middle part of the extrahepatic bile duct, the pancreas head, and the supraglottis]

An 83-year-old man was admitted to our institution for the purpose of investigation of hoarseness in January 2014. He was diagnosed with cancer in the supraglottis via biopsy while undergoing laryngeal microsurgery. Positron emission tomography (PET)evaluation for tumor staging revealed two hot spots, 1 in the hepatoduodenal ligament and 1 in the pancreas head. Accordingly, the patient was diagnosed with synchronous double cancer in the middle bile duct and the pancreas head. The treatment of the bile duct cancer and pancreatic cancer was performed prior to that of the supraglottic cancer. Curative pancreatoduodenectomy was performed, and the postoperative course was uneventful. Three weeks after the surgery, chemoradiotherapy for the supraglottic lesion was initiated. The tumor almost disappeared 2 months after the start of chemoradiotherapy, as observed by using a laryngoscope. Multidisciplinary therapy based on the therapeutic guidelines for each of the cancers was beneficial for the patient.

Prevalence of human papillomavirus infection in Greek patients with squamous cell carcinoma of the larynx

BACKGROUND/AIM

The causal relation between human papillomavirus (HPV) infection and squamous cell carcinoma (SCC) of the larynx has not been yet clarified. The aim of the present study was to investigate HPV infection in 54 SCC of the larynx and correlate it with patients' epidemiological and clinicopathological data.

MATERIALS AND METHODS

Fifty-four biopsies were collected from patients with laryngeal SCC and tested for HPV DNA. Local recurrence analysis was performed at the 2- year follow-up.

RESULTS

HPV DNA was detected in 18.5% (10/54) of laryngeal SCC; infection from high risk (hr) HPV and low risk (lr) HPV types was found in 16.7% (9/54) and 1.8% (1/54) of the samples, respectively. HPV 16 was the commonest type detected in 7.5% (4/54). The presence of HPV DNA was significantly associated with the absence of tobacco use (p=0.001) and poorly differentiated tumors (p=0.003).

CONCLUSION

This study confirms the prevalence of HPV infection among patients with SCC of the larynx.

[Total laryngectomy using a linear stapler for laryngeal cancer]

Total laryngectomy is a well established method for the treatment of laryngeal cancer. In some cases such as elderly patients or patients with severe complications, a shorter surgical time is preferred. Total laryngectomy using a linear stapler is reportedly advantageous for shortening of the surgical time and for lowering the rate of pharyngeal fistula formation. We applied this surgical technique in three laryngeal cancer cases. After skeletonization of the larynx, the linear stapler is inserted between the larynx and the pharyngeal mucosa. Excision of the larynx and suturing of the pharyngeal mucosa are performed simultaneously. Although the number of cases is small for statistical analysis, the surgical time was shortened by about 30 minutes compared to laryngectomy with manual suturing. Total laryngectomy by linear stapler cannot be applied in all cases of advanced laryngeal cancer. However, if the tumor is confined to the endolarynx, it is a useful tool for some cases that require a shorter surgical time.

[Restoration of esophageal passability in recurrences of tumours of various localization]

Experience of the esophageal passability restoration in tumoral recurrences of various localization was presented, basing on analysis of the treatment results in 29 patients. Preliminary bougienage and balloon dilation of the tumoral stricture zone have promoted reduction of the complications occurrence risk, caused noncontrolled action of a self expanding stent.

[Research on the association of the laryngeal carcinoma and laryngopharyngeal reflux]

OBJECTIVE

The objective of this study is to investigate the association between laryngeal carcinoma and laryngopharyngeal reflux.

METHODS

This was a case-control study with 31 laryngeal cancer patients who had undergone 24-hour ambulatory double pH monitoring and 76 in the control group which were divided into negative group (36 patients) and positive group (40 patients) by the score of RSI (reflux symptom index) and RFI (reflux findings index) scale. The results of reflux and parameters of 24-hour ambulatory double pH monitoring among the three groups were statistically analysed.

RESULTS

The smoking rate of 80.6% (25/31) in laryngeal carcinoma group was significantly higher than that of (36.1%, P < 0.0167) in the negative group while it did not vary in laryngeal carcinoma group and the positive group (65.0%, P > 0.0167). The drinking rate of 71.0% (22/31) in laryngeal carcinoma group was higher than that of (36.1%, P < 0.0167) in the negative group whereas there was no significant difference between laryngeal carcinoma group and positive group (50.0%, P > 0.0167). The positive rate of laryngopharyngeal reflux in laryngeal carcinoma group, the positive group, the negative group were 74.2% (23/31), 16.7% (6/36) and 52.5% (21/40) respectively, which was significantly different (P < 0.05). The positive rate of gastroesophageal reflux in the three groups above were 71.0% (22/31), 52.8% (19/36) and 75.0% (30/40), which had no significant difference (P > 0.05). The positive rate of laryngopharyngeal reflux differed in laryngeal carcinoma group and the negative group (P < 0.0167) while did not differ in laryngeal carcinoma group and the positive group (P > 0.0167). In the results of 24-hour ambulatory double pH monitoring, there was significant difference in the total and upright reflux number, the total reflux time, the percent times for the pH falling below 4, total reflux number which lasted more than 5 minutes and DeMeester Scores.

CONCLUSIONS

The positive rate of laryngopharyngeal reflux in laryngeal carcinoma group was very high while the drinking and smoking rate were also high. Therefore whether the laryngopharyngeal reflux is a risk factor of the laryngeal carcinoma, it needs further research.

Beware: unilateral Reinke's oedema of the larynx

A thirty year-old man presented with hoarseness of recent onset. The underlying cause was a glottic schwannoma, which led to development of unilateral Reinke's oedema. Schwannomas arising in the paraglottic space are rare.

[Role of laryngopharyngeal reflux on the pathogenesis of vocal cord leukoplakia and early glottic cancer]

OBJECTIVE

To explore the significance of laryngopharyngeal reflux (LPR) and gastroesophageal reflux (GER) in patients with vocal cord leukoplakia and early glottic cancer.

METHODS

Patients with vocal cord leukoplakia and early glottic cancer encountered in Nanfang Hospital between December 2012 to January 2014 were included in this study. Ambulatory 24 hour multichannel intraluminal impedance-pH monitoring (MII-pH) was applied to obtain LPR and GER events, as well as the reflux properties of substances. Tobacco and alcohol history was also evaluated. Sixteen healthy volunteers were recruited as normal controls.

RESULTS

There were 26.3% (5/19) LPR patients in glottic cancer group, 35.3% (6/17) LPR patients in vocal cord leukoplakia group and 12.5% (2/16) LPR volunteers in normal controls. There was no statistically significant difference in the positive rate of LPR between early glottic cancer patients and normal controls as well as between vocal cord leukoplakia patients and normal controls (P > 0.05). There was statistically significance in numbers of acid reflux events, time of acid exposure, and time of acid clearance between vocal cord leukoplakia patients and normal controls as well as between glottic cancer patients and normal controls (P < 0.05). GER was found in 26.3% (5/19) patients in glottic cancer group and 23.5% (4/17) patients in vocal cord leukoplakia group and 6.3% (1/16) volunteer in normal controls. There was no statistically significant difference in the positive rate of GER between early glottic cancer patients and normal controls as well as between vocal cord leukoplakia patients and normal controls (P > 0.05). However, there was statistically significance in DeMeester scores between glottic cancer patients and normal controls (P < 0.05), while no statistically significance between vocal cord leukoplakia patients and normal controls (P > 0.05). Reflux events were dominated by acid and weakly acidic reflux in upright position. Weakly alkaline reflux events in upright position, acid reflux events in supine position, and weakly alkaline reflux events in supine position in vocal cord leukoplakia patients were significantly more than those in normal controls (P < 0.05). No statistically significant difference existed in positions and contents between early glottic cancer patients and normal controls (P > 0.05). There was also no statistically significant correlation between happening LPR and GER, smoking and drinking in patients with vocal cord leukoplakia and early glottic cancer (P > 0.05).

CONCLUSIONS

Reflux events are more in vocal cord leukoplakia patients and early glottic cancer patients, however, the relationship between laryngopharyngeal reflux and canceration of the vocal cord is still needed to be investigated. The significance of mucosal injury induced by nonacid refluxes is needed to be further studies.

[Laryngopharyngeal reflux effect on expression of COX-2mRNA in glottic carcinoma]

OBJECTIVE

To investigate laryngopharyngeal reflux effect on expression of COX-2mRNA in glottis carcinoma lesion mucosa.

METHOD

Forty cases with glottic laryngeal cancer were examined by electronic naspharyngeal laryngoscope and scored by the reflux symptom index (RSI) and the reflux finding score(RFS). Based on the scores, they were divided into two groups:glottic laryngeal cancer with positive reflux(20 cases) and glottic laryn geal cancer with negative reflux (20 cases). Ten cases with adjacent normal membrane were used as control group. The mRNA expression of CoX-2 from 40 patients was examined by reverse transcription polymerase chain reaction (RT-PCR).

RESULT

The expression of COX 2mRNA in tumor samples was significantly higher than that in normal tissues (P < 0.05); the expression of COX-2mRNA in glottic laryngeal cancer with positive reflux was significantly higher than that in glottic laryngeal cancer with negative reflux (P < 0.05).

CONCLUSION

Laryngopharyngeal reflux factors may increased expression glottic carcinoma of COX-2mRNA by tissue injury, inflammation and cell malig-

Conservative cricoid surgery for chondrosarcoma: a case report

We present the case of a 39-year-old man who presented with hoarseness and progressively worsening dyspnea. Findings on laryngoscopy and computed tomography strongly suggested the presence of a chondrosarcoma. The patient underwent open surgery for removal of the lesion with wide margins. Reconstruction was carried out with two segments of costal cartilage. Laryngeal chondrosarcomas are rare, malignant, usually well-differentiated neoplasms that should be treated with conservative surgery. Recurrences should be treated more aggressively.

Acantholytic squamous cell carcinoma: pathological study of nine cases with review of literature

Squamous cell carcinoma (SCC) is classified in many subtypes or forms; one of them is the acantholytic squamous cell carcinoma, also called pseudoglandular, adenoid, epithelioma dyskeratoticum segregans, or adenoacanthoma. Researching and analyzing nine cases of acantholytic squamous cell carcinoma, we intend to verify if the data provided by the cases studied can be validated by the scientific literature. All the cases presented lesions found on the head and neck skin, with two exceptions - one on the larynx and the other one on the tonsil, all of them ulcerated lesions. In two cases, the tumors developed on the skin, in preneoplasic lesions (actinic keratosis). The tumors had dimensions between 4/3/4 mm and 100/90/36 mm. During one year, two of the cases studied presented multiple recurrences. We also found two cases of metatypical carcinoma accompanied the acantholytic variant of squamous cell carcinoma. None of the analyzed cases presented distant metastasis. The histopathological criteria for selection were: keratinised squamous tumor cell type, adenoid structures with round spaces with a defined wall of at least one cell width, spaces with isolated or grouped dyskeratotic acantholytic cells.

Pharyngolaryngeal location of Kaposi's sarcoma with airway obstruction in an HIV-negative patient

Kaposi's sarcoma (KS) is a human herpes virus-8 (HHV-8)-associated angioproliferative disorder, and its occurrence may be favored by human immunodeficiency virus (HIV) infection and iatrogenic immunosuppression. It has also been postulated that a chronic inflammatory disease of the skin can pave the way to its development. KS generally involves mucosal and cutaneous sites, including the head and neck. An oropharyngeal location is quite common, but laryngeal involvement with possible upper airway obstruction and respiratory distress requiring tracheotomy is rare, and no hypopharyngeal locations have yet been reported. We describe the case of a 68-year-old male patient who developed KS after immunosuppressive treatment for pemphigus vulgaris, an autoimmune bullous disease presenting with blisters and erosions on the skin and the oral mucosa. KS was initially localized to the oral cavity and oropharynx, but subsequent involvement of the laryngeal and hypopharyngeal tract led to acute airway obstruction and the need for tracheotomy. This unique case of pharyngolaryngeal KS suggests that clinicians faced with purple nodular lesions should consider a differential diagnosis of KS in immunocompromised patients, even if they are HIV negative, and should carefully manage the patency of the upper airways.

[Primary mucosal tuberculosis of head and neck region: a clinicopathologic analysis of 47 cases]

OBJECTIVE

To study the clinicopathologic features, histologic diagnosis and differential diagnosis of primary mucosal tuberculosis (TB) in the head and neck region.

METHODS

Forty-seven cases of primary mucosal TB of the head and neck region were studied by hematoxylin-eosin and Ziehl-Neelsen stains. The clinical and pathologic features were analyzed with review of the literature.

RESULTS

The patients included 26 male and 21 female, with mean age 47.1 years (range 14-84 years). There were three sinonasal TB, 19 nasopharyngeal TB, two oropharyngeal TB, 18 laryngeal TB, four middle ear TB, one salivary gland TB and one laryngeal TB complicating laryngeal cancer. The initial symptoms were nasal obstruction, mucopurulent rhinorrhea, epistaxis, snoring, hoarseness, dysphagia, odynophagia, serous otitis, hearing loss, tinnitus, and otalgia. Physical examination result was variable, from an apparently normal mucosa, to an evident mass, or a mucosa with an adenotic or swollen appearance, ulcers, leukoplakic areas, and various combinations thereof. CT and MRI findings included diffuse thickening, a soft-tissue mass, calcification within the mass and bone destruction resembling malignancy. Histologic examination showed granulomas with a central necrotic focus surrounded by epithelioid histiocytes and multinucleated Langhan's giant cells. Acid-fast bacilli were difficult to demonstrate but found in 13/45 cases. Follow-up data were available in 42 patients.

CONCLUSIONS

Primary TB arising in the head and neck mucosa is rare. It may mimic or co-exist with other conditions. The characteristic histopathology is a granuloma with central caseous necrosis and Langhans'giant cells. Identification of acid-fast bacilli and bacteriologic culture confirm the diagnosis of mycobacterial disease.

Association between infection of virulence cagA gene Helicobacter pylori and laryngeal squamous cell carcinoma

BACKGROUND

The aim of the study was to evaluate the presence of cagA gene Helicobacter pylori in etiopathogenesis of initiation and development of larynx squamous cell carcinoma (LSCC) and its predictable role as a prognostic factor.

MATERIAL AND METHODS

The prospective, controlled study involved a series of 75 patients (65 male, 10 female, mean age 59.1 years, range 43 to 79 years) with larynx cancer. Samples of larynx cancerous tissue, each of 10-15 mg, were obtained from fresh tissues and were used for nucleic acid purification. DNA was extracted from 225 samples (larynx tumor - I (75), margin of tumor and normal tissue - II (75) and normal larynx tissue from opposite side to the tumor - III). All samples were subjected to H. pylori ureA detection by the PCR H. pylori diagnostic test. Samples that were positive for ureA H. pylori gene were evaluated for cagA H. pylori gene.

RESULTS

Presence of H. pylori cagA gene was identified in 46,7% to 49,3% of 75 H. pylori ureA gene-positive larynx cancer depending of tissue location. There was a correlation of high incidence of positive cagA gene in larynx cancer tissue in supraglottic versus subglottic and glottic location. We observed a predominance of cagA gene in LSCC in patients with positive cervical lymph nodes and clinical stage T3 and T4.

CONCLUSIONS

H. pylori is present in larynx tissue and may be a possible carcinogen or co-carcinogen in LSCC development, but that must be addressed by future investigations. The presence of cagA gene in larynx cancer tissues significantly decreases survival rate and increases the disease recurrence possibilities.

Function preservation using transoral laser surgery for T2-T3 glottic cancer: oncologic, vocal, and swallowing outcomes

Aim of this study was to retrospectively analyze oncologic and functional results of a cohort of T2 and selected T3 glottic tumors treated by transoral laser surgery (TLS). Eighty-nine patients affected by T2 and T3 glottic tumors were treated by TLS from 2005 to 2010 at an academic institution by Type V cordectomies using an "en bloc" or, more frequently, a "piece-meal" technique depending on a number of variables. Kaplan-Meier curves were used to evaluate 5-year overall, disease-specific survivals, local control with laser, and organ preservation rates. Univariate analysis of the impact of different variables was performed. At least 1 year after surgery, we examined: subjective voice evaluation by voice handicap index (VHI), perceptive analysis by GRBAS scale, objective measurements with multidimensional voice program (MDVP), swallowing assessment with the M.D. Anderson Dysphagia Inventory (MDADI), videonasal endoscopic evaluation of swallowing (VEES), and videofluoroscopy (VFS). Fifty-nine patients were pT2 and 30 pT3. The 5-year overall, disease-specific survivals, local control with laser, and organ preservation rates were 92.4, 98.7, 68.5, and 82.1 %, respectively. VHI mean score was 20 (mild dysphonia). Mild and moderate dysphonias were detected by GRBAS in 82 and 18% of patients, respectively. Mean values of Jitter, Shimmer, and noise-to-harmonic ratio by MDVP resulted 7.87%, 24.8%, and 0.37, respectively. Mean value of MDADI was 95.75. Only 2% of patients at VEES and 4% at VFS showed tracheal aspiration. Our results highlight that T2 and selected T3 glottic tumors treated by TLS have favorable oncologic and functional outcomes.

Retrospective analysis of prognostic factors in 205 patients with laryngeal squamous cell carcinoma who underwent surgical treatment

Objectives

To investigate the most important factors affecting the prognosis of the patients with squamous cell carcinoma (SCC) of the larynx.

Methods

Based on the clinical and follow-up data, 205 patients with SCC of the larynx receiving total laryngectomy, partial laryngectomy, or CO₂ laser surgery in GuangDong General Hospital were retrospectively analyzed. A survival analysis was performed by the Kaplan-Meier method and a multivariable analysis of prognostic factors was carried out using the Cox proportional hazard model.

Results

Subtypes of carcinoma included 69.8% glottic and 30.2% supraglottic. Most patients were in N0 stage (77.6%), and 22.4% patients were in N1∼N3 stage. Over half of the patients were in T1∼T2 stage (55.1%), 20.0% in T3, and 24.9% in T4. Mean follow-up duration was 49.2 months. The survival rates 1, 2, and 3 years after the surgery were 99.0%, 91.7%, and 81.5%, respectively. The survival rate for those patients with clinical stage IV was significantly lower than for those with clinical stage I and II (p<0.001 and p = 0.013, respectively). The disease-free progression rates 1, 2, and 3 years after the surgery were 83.9%, 74.6%, and 71.2%, respectively. Futhermore, those patients with a Charlson score of 1 to 2 and ≥3 had higher risk of mortality than those with a Charlson score of 0 (hazard ratios of 1.8 and 2.41 p = 0.042 and p = 0.008). Multivariable analysis revealed that clinical stage, surgical margin, and comorbidity were significantly associated with both mortality and disease-free progression.

Conclusion

The surgical resection margin, clinical stage, and comorbidity were independent factors affecting the laryngeal cancer prognosis. The survival rates were lower for patients with advanced laryngeal cancer, positive surgical margins, or severe comorbidity, suggesting the importance of early diagnosis, early treatment, negative surgical margins, and conditions of comorbidity.

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.

[Restoration of the vocal function in the patients with laryngeal cancer after organ-saving surgery]

The objective of the present study was to enhance the effectiveness of vocal rehabilitation and to improve the quality of life in the patients presenting with laryngeal cancer after organ-preserving surgical interventions. The study included 98 patients presenting with stage II-III laryngeal cancer who underwent organ-preserving surgery and postoperative vocal rehabilitation. The comprehensive approach to the restoration of the vocal function has been developed and clinically applied that includes rational psychotherapy, respiratory gymnastics for the correction of physiological and phonation breathing, activation of the neuromuscular apparatus of the external and the residual internal larynx and neck muscles , coordination of the vocal apparatus at the expense of compensation of the remaining part of the larynx taking advantage of the biological feedback mechanism based on the results of mathematical simulation. The application of this approach in clinical settings made it possible to increase the effectiveness of vocal rehabilitation up to 93%, reduce the number of disabled subjects, restore the working abilities in the patients of the employable age, significantly promote their social adaptation, and improve the life quality.

Infiltrative laryngeal lipoma in a Yorkshire Terrier as cause of severe dyspnoea

A 10-year-old Yorkshire Terrier with suspected laryngeal paralysis was referred for further examination and surgical treatment. The dog displayed severe dyspnoea and dysphonia. Ventrolateral to the larynx a soft-elastic mass of 2 cm diameter was palpated and confirmed by radiography. Histopathological examination of the resected mass revealed an infiltrative lipoma/lipoma. Although the dog totally recovered after surgery, the prognosis remains guarded due to the high risk of a recurrence. Tumours of the larynx in general and an infiltrative lipoma specifically should be added to the list of differential diagnosis in dogs presented with clinical signs that could be misinterpreted as laryngeal paralysis.

Influential factors, complications and survival rate of primary and salvage total laryngectomy for advanced laryngeal cancer

This is a retrospective review of patients with advanced malignant neoplasms of the larynx treated with total laryngectomy. 387 total laryngectomies for advanced squamous cell carcinoma of larynx performed in the period between 1995 and 2007 were analyzed. Primary total laryngectomy (PRT) was performed in 316 patients, while initial radiotherapy radiotherapy (60-70 Gy) and concomitant chemotherapy (cisplatin-5 fluorouracil) with radiotherapy were applied in totally 71 patients who later received salvage total laryngectomy (STL). All the laryngectomies were performed by four surgeons, using the same routine surgical technique. Postoperative clinical examination was made every three months during five years. We documented the occurrence of: local and general complications, survival rate, residual and recurrent disease, lymph node metastasis, and other changes. Salvage total laryngectomy after previous radiotherapy (STL-pRT) and after chemoradiotherapy (STL-pCTRT) caused more frequent local complications than primary total laryngectomy (PTL). TNM stage and localization of primary laryngeal tumor had significant influence on five year survival rate. It amounted: 61.4% for PTL, 52.6% for STL-pCTRT, and 48.5% for STL-pRT. Incomplete response to initial treatment produced low survival rate. Salvage total laryngectomy caused more frequent local complications, especially after chemoradiotherapy when compared to primary laryngectomy. Survival rate was increased when chemotherapy is added to radiotherapy. Five year survival rate depended on TNM stage and localization of primary tumor.

Laryngeal cancer and silica dust exposure: a systematic review and meta-analysis

BACKGROUND

Individual epidemiological studies generally lack the power to examine the association between silica exposure or silicosis and laryngeal cancer. We summarized pertinent evidence from published literature by using meta-analysis.

METHODS

A systematic literature search was performed to identify cohort and case-control studies, and the method of meta-analysis was used to combine standardized mortality ratios (SMRs) or standardized incidence ratios (SIRs) from cohort studies and odds ratios (ORs) from case-control studies.

RESULTS

A significantly increased risk of laryngeal cancer (pooled OR = 1.39, 95% confidence interval (95% CI): 1.17-1.67) among workers exposed to silica dust was observed by combining six case-control studies with adjustment for smoking and alcohol consumption. A similarly increased but statistically non-significant risk estimate was observed from cohort studies, with a pooled SMR of 1.38 (95% CI: 0.79-1.96) for silicosis cases; and a pooled SMR of 1.13 (95% CI: 0.82-1.45) and a pooled SIR of 1.50 (95% CI: 0.59-2.42) for workers with silica dust exposure.

CONCLUSION

This systematic review demonstrated a weak association between silica or silicosis and laryngeal cancer. Owing to the inherent limitations of the original studies, interpretation of the results of this meta-analysis should be cautious.

Extramedullary plasmacytoma of the true vocal fold

We report a rare case of extramedullary plasmacytoma (EMP) of the true vocal fold. Our patient, a 62-year-old woman, presented with dysphonia. On workup, fiberoptic laryngoscopy detected a lesion arising from the anterior half of her left true vocal fold. No evidence of other pathology was noted. The patient underwent radical radiotherapy, and the lesion resolved. Follow-up revealed no sign of recurrence. A type of myeloma, EMP is rare, especially in the larynx. To the best of our knowledge, our patient represents the sixth case of glottic EMP to be reported in the literature.

Primary angiosarcoma of the larynx: a rare entity

Angiosarcomas are extremely rare malignant tumours of the larynx. We present a case of laryngeal angiosarcoma in a 58-year-old man who presented with hoarseness of voice, dysphagia and neck swelling. The patient underwent a total laryngectomy with a pre-operative and frozen section diagnosis of a poorly differentiated carcinoma of the larynx. Histopathological and immunohistochemical evaluation revealed features of a laryngeal angiosarcoma. The case is presented for its rarity and diagnostic difficulty.

Presentation of laryngeal papilloma in childhood: the Leeds experience

INTRODUCTION

The human papilloma virus (HPV) can cause laryngeal papillomatosis in childhood. The aetiology is thought to be vertical transmission. Clinically these children are usually asymptomatic for the first 6 months of life. As the papillomas develop locally, symptoms begin to develop. The symptoms range from voice change to frank hoarseness, and 'noisy' breathing, most commonly inspiratory stridor.

METHOD

Clinical images from microlaryngoscopy and bronchoscopy over a 12-year period were assessed for laryngeal papilloma.

RESULTS

In Leeds seven cases presented to the specialist centre over the past 12 years, the average age at presentation was 6.8 years and duration of onset of symptoms to specialist review was 21 months. Five of the children had been treated for asthma and two presented in extremis.

CONCLUSION

The take home message for clinicians is hoarse voice associated with shortness of breath needs specialist referral.

Primary composite lymphoma of the larynx, composed of diffuse large B-cell lymphoma and peripheral T-cell lymphoma, not otherwise specified, presenting as left subglottic tracheal fistula, esophageal diverticulum, and neck abscess

Primary laryngeal lymphoma occurs very rarely, accounting for far less than 1% of primary malignant laryngeal neoplasms. To the best of our knowledge, primary laryngeal composite lymphoma has not been reported in the literature. Herein, we report the first case of primary laryngeal composite lymphoma composed of diffuse large B-cell lymphoma (DLBCL) and peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS), in a 43-year-old man. Of special interest is the patient's unique clinical presentation of left subglottic tracheal fistula, esophageal diverticulum, and neck abscess with no discrete mass identified. We describe the clinical and pathological characteristics of this case and review the literature.

Factors influencing quality of life after total laryngectomy: a study of 92 patients

BACKGROUND AND OBJECTIVES

Total laryngectomy is a radical surgery for advanced laryngeal cancer. In the present study we evaluate the influencing factors for long term quality of life of 92 laryngectomees.

PATIENTS AND METHODS

92 patients who underwent laryngectomy for laryngeal cancer in the University Hospital of Patras, Greece were evaluated using a modified version of the EORTC-QOL-C30 questionnaire. The patients were distributed into 6 groups based on time elapsed between surgical treatment and completion of the questionnaire, ranging from 2 years for group 1 to 9-10 years for group 6.

RESULTS

The mean value of psychological status (p=0.01), smelling disorders (p=0.032), mood change (p=0.003) were statistically significant in regard to the patient's overall view of their life postsurgically. Coexisting illness (defined as diabetes, hypertension or prostate disease which required medication on daily basis or hospitalization more than two times a year) was also significantly affecting (p=0.021) the patient's oral communication skills.

CONCLUSION

Quality of life is affected by functional disabilities and the psychological state of the patients. No statistically significant improvement over time was noted in our series.

Twist modulates lymphangiogenesis and correlates with lymph node metastasis in supraglottic carcinoma

BACKGROUND

Twist is a highly conserved epithelial-mesenchymal transcription factor that has been reported to be a key factor in tumor malignancy, including lymph node metastasis. It represents the major step of dissemination and serves as a chief prognostic indicator of disease progression. However, the mechanism by which Twist regulates lymph node metastasis remains incompletely understood. Studies on the mechanism of metastasis are thus required for determining appropriate therapeutic strategies.

METHODS

Immunohistochemistry for lymphatic vessel endothelial receptor 1 (LYVE-1), Ki-67, Twist, vascular endothelial growth factor C (VEGF-C), and vascular endothelial growth factor receptor 3 (VEGFR-3) was performed to detect lymphatic vessel density (LVD), cell proliferation levels and the expressions of Twist, VEGF-C, and VEGFR-3 were determined from 66 primary supraglottic carcinoma tissue samples from 36 patients with lymph node metastasis (pathological N+, pN+) and 30 patients without metastasis (pathological N0, pN0). Western blotting analysis of the proteins in pN+ and pN0 primary tumors was used to characterize the expressions of Twist, VEGF-C, and VEGFR-3 further.

RESULTS

The LVD was 22.4 ± 10.3 in pN+ patients and 6.8 ± 4.1 in pN0 ones. For Ki-67, the number of proliferous cells in pN+ patients was greater than that in pN0 ones. Both, however, were associated with their clinical nodal stages. In pN+ patients, Twist, VEGF-C, and VEGFR-3 expressions were 86.11% (31/36), 80.56% (29/36), and 58.33% (21/36), respectively. These values were higher than those found for pN0 patients (i.e., 13/30, 11/30, and 7/30, respectively) (P < 0.05). Among the samples with Twist expression, 88.64% were VEGF-C-positive and 59.09% were VEGFR-3-positive. The pN0 counterparts were 4.55% and 9.09%, respectively (P < 0.05). The expressions of Twist, VEGF-C, and VEGFR-3 in pN+ patients obtained through Western blotting analysis were significantly higher than those in pN0 patients, and the levels of VEGF-C and VEGFR-3 were positively correlated with that of Twist.

CONCLUSIONS

Twist expression correlates with lymph node metastasis. The mechanism involved in such a correlation may be related to lymphangiogenesis.

Subglottic stenosis induced by extranodal mucosa-associated lymphoid tissue lymphoma

Mucosa-associated lymphoid tissue (MALT) lymphoma is usually associated with a chronic inflammatory disease or autoimmune disorders from which lymphoid tissue of MALT type arises as a prerequisite for lymphoma proliferation. Primary hematopoietic neoplasms of the larynx are rare. MALT lymphomas of the larynx are believed to arise from preexisting or acquired lymphoid tissue of the upper airway which is documented in the supraglottic region. Therefore, these are mainly located in the supraglottic and glottic areas, with only a few reported in the subglottic region. We report on a 50-year-old woman with a hoarseness, stridor, and developing exertional dyspnea. On indirect laryngoscope, multiple nodular lesions with smooth surface over the subglottis with subglottic steonsis was found. The biopsy confirmed the diagnosis of a MALT lymphoma. We hope to promote awareness and consideration of MALT lymphoma in the differential diagnosis in subglottic steonsis.

Laryngeal tumours: clinical pattern in Sokoto, Northwestern Nigeria

BACKGROUND

Laryngeal tumours may be benign or malignant presenting with progressive voice hoarseness and upper airway obstruction which may be misdiagnosed.

METHOD

Patients were prospectively recruited over 6years from July 1999 to July 2005 in a tertiary health centre.

RESULTS

Thirty seven cases of laryngeal tumours were seen (30 males (81.1%), 7 females (18.9%). The incidence was 6.2 cases per year. Histological diagnosis was only obtained in 30 patients (25 (83.3%) males, 5 females (16.7%). The age range was 3 months to 75 years with the mean ages (benign 6.1 years, and malignant 47.9 years). Histology of the 30 patients showed 20 (66.7%) to be malignant (Squamous cell carcinoma) out of which 17 (85%) were males and 3 (15%) females with male to female sex ratio of 5.7:1. Ten (33.3%) of the 30 cases were benign out of which 8 were males (80%) and 2 females (20%) with male to female sex ratio of 4:1.Malignant cases who had total laryngectomy, selective neck dissection with radiotherapy lived longer (minimum of 4 years) than those who had only total laryngectomy (maximum of 2(1/2) years) or only radiotherapy (6 months - 1 year). There was recurrent nodal neck lesions in 6 (30%) patients, five of which did not go for radiotherapy after surgery while one had postoperative radiotherapy. Two of these died from carotid artery rupture. Two female patients with malignant tumor who had total laryngectomy had babies born through safe vaginal delivery but eventually succumbed to the disease.

CONCLUSION

There were more malignant (66.7%) laryngeal tumors than benign (33.3%) lesions with a male preponderance and strong association with cigarette smoking but no alcohol consumption. The mean age for malignant lesions was 47.9 years which signifies a considerably younger population while that of benign lesion was 6.1 years.

Laryngocele associated with laryngeal carcinoma

Laryngocele is an abnormal dilatation of Morgagni ventricle (saccule) in direct communication with the laryngeal lumen. Symptoms are not characteristic: hoarseness, dyspnea, foreign body sensation and cough. Sometimes it is presented as cervical swelling causing airway obstruction and need an emergency tracheotomy. In this paper, we report a case of upper airway obstruction due to laryngocele associated with a laryngeal carcinoma who was treated by emergency tracheotomy and, finally by total laryngectomy. A review of the literature is also presented.

[Helicobacter pylori infection: a potential pathogenic factor for laryngeal squamous cell carcinoma]

OBJECTIVE

To investigate the difference in Helicobacter pylori (Hp) infection rate between the patients with laryngeal squamous cell carcinoma and the patients with benign laryngeal lesions and to explore the role of Hp infection in the pathogenesis of laryngeal squamous carcinoma.

METHODS

Nested polymerase chain reaction (nPCR) and Hp culture were used to identify the Hp in laryngeal mucosa in 30 patients with laryngeal carcinoma and 15 patients with benign laryngeal lesions including polyps of vocal cords or epiglottic cysts.

RESULTS

nPCR showed that Hp-positive rate (73.3%) of patients with laryngeal carcinoma was significantly higher than that (20.0%) of control patients with benign laryngeal lesions (χ(2) = 11.520, P = 0.010). Regarding the 22 positive neoplastic cases that have 44 tissues, out of the 22 tumor tissues, 10 were positive with Hp (45.4%), and among 22 tissues beside the tumor, 19 were positive (86.4%). This event also indicated a statistical significance (χ(2) = 4.697, P = 0.030). Hp culture showed that Hp was negative in all specimens.

CONCLUSIONS

Hp exist in the laryngeal mucosa, but with the higher rate of Hp infection in the patients with laryngeal squamous cell carcinoma than that in the patients with benign laryngeal lesions, which suggests Hp may be one of pathogenic factors of laryngeal squamous cell carcinoma.

Propranolol for the treatment of airway hemangiomas: a case series and treatment algorithm

OBJECTIVES

(1) To present six patients with symptomatic airway hemangiomas treated with oral propranolol. (2) To review the diagnostic and treatment options for airway hemangiomas and propose a new management protocol.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care children's hospital.

SUBJECTS AND METHODS

Pediatric patients diagnosed with obstructive airway hemangiomas treated with oral propranolol. Patients were followed for symptomatic improvement and relief of airway obstruction on imaging or laryngoscopy.

RESULTS

Seven patients presenting with airway obstruction were treated with propranolol. One patient had a focal hemangioma confined to the subglottis. Four patients had airway hemangiomas that extended beyond the confines of the larynx and trachea. A sixth patient had a bulky supraglottic hemangioma. A seventh patient with an extensive maxillofacial lesion failed propranolol therapy and was found to have a pyogenic granuloma on final pathology after excision. Six patients had failed standard medical therapy and/or surgical interventions and were treated successfully with oral propranolol with improvements in airway symptoms and oral intake, requiring no further surgical intervention. Treatment was initiated as early as 1.5 months of age, and as late as 22 months. No adverse side effects of propranolol were noted.

CONCLUSIONS

Oral propranolol was successfully used to treat airway hemangiomas, resulting in rapid airway stabilization, obviating the need for operative intervention, and reducing the duration of systemic corticosteroid therapy while causing no obvious adverse effects. These outstanding results enable the possibility of use of a standardized diagnostic and treatment algorithm for airway hemangiomas that incorporates systemic propranolol.

Recurrent vascular leiomyoma of the larynx: clinical and histopathologic characteristics and treatment

Laryngeal vascular leiomyomas are uncommon benign tumors that seldom recur following complete excision. The choice of excision procedure-via direct laryngoscopy or an open approach-is dictated by tumor size, the expected amount of blood loss, and any comorbidities the patient may have. We report an unusual case of a recurrent laryngeal vascular leiomyoma in a 64-year-old woman who also had a concurrent parathyroid adenoma and a history of breast carcinoma. A surgical resection via an external approach along with laser resection of a small glottic component was needed.

Distal marginal stenosis: a contributing factor in delayed carotid occlusion of a patient with carotid blowout syndrome treated with stent grafts

Distal marginal stenosis is rarely reported to be a factor associated with poor long-term patency of patients of head and neck cancers with carotid blowout syndrome treated with stent grafts. We report a case of laryngeal cancer with rupture of the right common carotid artery. A self-expandable stent graft was deployed, but bleeding recurred. Another stent graft was deployed for the pseudoaneurysm located distal to the first stent graft. Rebleeding occurred because of pseudoaneurysm formation from reconstituted branches of the right superior thyroid artery. We performed direct percutaneous puncture of the proximal superior thyroid artery for successful embolization. Distal marginal stenosis and asymptomatic thrombosis of the carotid artery were noted at 3.5- and 5-month follow-ups, respectively. We suggest aggressive early follow-up and reintervention for distal marginal stenosis by combined antibiotic therapy and angioplasty and stenting to improve the long-term patency of stent-graft deployment for management of carotid blowout syndrome.

[Acute respiratory stridor in infancy]

Infantile subglottic hemangioma is a pediatric tumor of endothelial cells characterized by an initial phase of rapid proliferation (around 6 months), followed by slow involution, often leading to complete regression following the first year of life. It is most frequently found in females and it usually it occurs also in the skin. From its position it can cause a progressive airway obstruction, so early diagnosis and treatment are very important. Many treatments have been described in the literature, including systemic steroids, intralesional steroid injection, carbon dioxide laser therapy, submucous resection, interferon alfa-2 and also tracheostomy as last approach. This case report discusses a 6-month old infant, that arrived to our attention for an acute two-way stridor. Laringoscopy under general anesthesia showed a subocclusive subglottic haemangioma that closed 70% of the laryngeal airway. In agreement with our ENT specialist it was decided to begin systemic steroid therapy, first by i.v. ingection during intensive therapy with rinotracheal intubation and mechanic ventilation; after the canula removal and the hemangioma reduction, the patient took oral steroids with a gradual reduction of the dose. This case evidences the importance of laryngoscopy in the diagnosis of subglottic haemangioma; it also proves the importance of multi-disciplinary collaboration with ENT specialist and dermatologist for the diagnosis and treatment of this kind of patient. It also shows that systemic steroids are an effective alternative in the management of obstructive pediatric subglottic hemangiomas.

Office-based treatment of vocal fold polyp with flexible laryngosvideostroboscopic surgery

OBJECTIVES

To evaluate the usefulness and safety of flexible laryngovideostroboscopic (FLVS) surgery in patients with vocal fold polyp and to discuss its advantages and limitations in comparison with traditional direct microlaryngoscopic technique under general anesthesia.

DESIGN

Retrospective analysis.

PATIENTS AND METHODS

Twenty patients with vocal fold polyp treated by FLVS surgery under topical anesthesia were reviewed. The results were evaluated by videostroboscopy and grade of the severity of dysphonia, roughness, and breathiness (GRB) scales. Phonatory results, including maximum phonation time, jitter, shimmer, and noise to harmonic ratio, were also reviewed for objective evaluations.

RESULTS

All patients completed the surgery smoothly, and seven of them had a higher risk for general anesthesia because of their medical diseases. The procedure was typically accomplished within 20 minutes, and no complications were noted. Videostroboscopy showed improved degree of glottic closure (p < .001), regularity (p = .046), phase symmetry (p = .008), and mucosal wave (p = .008) after FLVS. A significant improvement was noted between preoperative and postoperative results with regard to GRB scale (p < .001, p = .001, and p = .013, respectively). Maximum phonation time also increased significantly after surgery (p = .002). Trivial mucosal residual was noted in one patient. No recurrence was found after a 6-month follow-up period.

CONCLUSIONS

FLVS surgery is a highly applicable procedure with low invasiveness and minimal morbidity. It offers a simple and cost-effective alternative to the traditional direct microlaryngoscopic procedure, especially for those who are not candidates for general anesthesia or suspension of the larynx.