[Fiberoptic tracheal intubation aided by jaw lifting in a patient with an epiglottic cyst]

Epiglottic cyst is known to cause difficult intubation. We report a patient with an epiglottic cyst whose trachea was successfully intubated with the aid of fiberoptic bronchoscopy combined with the jaw lift maneuver. A 29-year-old patient was scheduled for lumbar disk hernia surgery. On the first occasion, surgery was cancelled since the patient was unexpectedly found to have an epiglottic cyst and tracheal intubation was not possible. Two weeks later, nasotracheal intubation guided by fiberoptic bronchoscopy under conscious sedation was planned. On the first attempt of bronchoscopy, the glottic view was obscured by the cyst displacing the epiglottis posteriorly. Next, we applied the jaw lift maneuver in conjunction with bronchoscopy. The maneuver improved the glottic view by clearing the epiglottis from the posterior pharyngeal wall and the patient's trachea was successfully intubated. Jaw lifting could be a useful adjunct to fiberoptic bronchoscopy for tracheal intubation in patients with epiglottic cysts.

Severe epiglottic prolapse and the obscured larynx at intubation

Laryngomalacia is the most common congenital anomaly of the larynx and usually involves prolapse of the arytenoids, so-called 'posterior laryngomalacia'. Most cases resolve with growth of the child and maturation of the larynx, although, rarely, significant airway obstruction can be present. Severe laryngomalacia preventing intubation is rarely encountered. We report a case of a difficult emergency intubation secondary to 'anterior laryngomalacia' in a 4-month-old boy in whom the epiglottis prolapsed posteriorly and became trapped in the laryngeal introitus. The child was referred with a diagnosis of laryngeal atresia on the basis of the intubating laryngoscopic view of no apparent epiglottis or laryngeal inlet. The child was transferred with a tube in the oesophagus that kept the child oxygenated. At the time, oxygenation was felt to be due to a coexisting tracheo-oesophageal fistula, although this was eventually found not to be the case.

Functional analysis after supracricoid partial laryngectomy with cricohyoidoepiglottopexy

OBJECTIVES

To assess prospectively speech and swallowing function in a series of 17 patients after supracricoid partial laryngectomy with cricohyoidoepiglottopexy.

STUDY DESIGN

Retrospective study.

METHODS

From 1983 to 1996, 69 patients at Department of Otolaryngology-Head and Neck Surgery, CHUV (Lausanne, Switzerland) underwent a supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Seventeen of them (25%) could be contacted and accepted participation in a functional evaluation that included a questionnaire to document their present nutritional status and diet. A formal voice evaluation was also performed, which included psychoacoustic evaluation of vocal qualities, fundamental frequency parameters, phonation intensity range, phonatory quotient (vital capacity divided by maximum phonation time), and a laryngeal video laryngoscopy performed with a rigid endoscope.

RESULTS

Median postoperative follow-up was 66 months (range, 12-152 mo). Nine of 17 patients (53%) recovered a normal diet with no increased incidence of aspirations. Seven of 17 had minor limitations such as no peanuts, dry bread, or rice. Two of 17 patients were restricted to pureed food. Assessment of voice showed a clearly decreased mean fundamental frequency at 70.1 Hz (normal range, 121-211 Hz) and a narrowed frequency range of phonation with a mean value of 8.8 semitones (normal value, 27). Forty-two percent of the patients went back to their normal professional life after the operation. Among the 10 who did not, 3 (16%) retired and 7 actually had to give up their profession, because of the modification of their voice or general asthenia and age close to retirement.

CONCLUSION

Restoration of laryngeal function after supracricoid partial laryngectomy with cricohyoidoepiglottopexy is satisfactory. Although most of the patients seem to recover normal swallowing function, severe voice alterations appear to be inevitable.

Atypical isolated epiglottic tuberculosis: a case report and a review of the literature

Tuberculosis is a systemic disease and its occurrence in the larynx and in the oral cavity is well-documented in the literature. Tuberculosis of the larynx involves mainly the vocal folds and the ventricular band and is associated with pulmonary tuberculosis in 80% of cases. Isolated epiglottic tuberculosis has rarely been described, and it is always associated with pulmonary lesions. The authors report a case of isolated epiglottic tuberculosis in a 72-year-old woman that presented as a laryngeal carcinoma and discuss the diagnostic problems related to its atypical clinical, endoscopic, and radiologic presentation.

A huge epiglottic cyst causing airway obstruction in an adult

An epiglottic cyst causing airway obstruction is rare in an adult. Early definitive diagnosis and management obviate an unnecessary tracheostomy. We report a case of a 64-year-old woman who arrived at our hospital with progressive stridor and foreign body sensation when swallowing for 6 weeks. A hot potato voice and biphasic stridor were remarkable upon physical examination. Indirect mirror and fibroscopic examination revealed a huge epiglottic cyst. The neck lateral X-ray and computed tomography scan demonstrated a huge cystic mass over the epiglottis. A 2.5 x 3.0 cm cystic mass was removed with endoscopic CO2 laser after needle decompression. The patient was discharged on the third day after surgery without complications. An epiglottic cyst in an adult seldom causes upper airway obstruction and is easily ignored by clinicians. We emphasize that complete airway evaluation including routine check-up of the larynx is mandatory for patients with intractable obstructive airway disease. Endoscopic laser surgery is effective in the surgical removal of an epiglottic cyst.

Epiglottic hematoma leading to airway obstruction after general anesthesia

Bleeding into the upper airway can cause airway obstruction and death if not recognized promptly. Anesthesiologists are quite familiar with potential airway obstruction from acute epiglottitis, but they may be less familiar with the potential for airway obstruction from epiglottic hematoma. We report what we believe is the second case of epiglottic hematoma after anesthesia and surgery that led to an acute upper airway obstruction. Our case was unique in that there was no excessive airway trauma during tracheal intubation. Most important, this case emphasizes that patients receiving multiple anticoagulants--as our patient was--are at risk for airway bleeding, epiglottic hematoma formation, and airway obstruction.

Upper respiratory tract carcinoma with chromosomal translocation 15;19: evidence for a distinct disease entity of young patients with a rapidly fatal course

BACKGROUND

Carcinoma of the upper respiratory tract is rare in childhood, and cytogenetic aberrations have not been characterized in this population. The chromosomal translocation 15;19 has been reported four times previously. All patients were young and had tumors arising in the thorax. The three reports that provide clinical follow-up all describe superior vena cava syndrome and death soon after presentation. All tumors were diagnosed as carcinoma (three undifferentiated, one mucoepidermoid), and the authors suggested thymus, lung, or germ cell origin.

METHODS

The authors investigated the clinical and pathologic findings in two patients with poorly differentiated carcinoma showing evidence of t(15;19). This included a 13-year-old girl with a rapidly growing epiglottic mass, leading to superior vena cava syndrome and death and a 12-year-old girl with an aggressive nasopharyngeal mass showing intracranial extension.

RESULTS

The laryngeal tumor was poorly differentiated, with vesicular nuclei, prominent nucleoli, extensive necrosis, and a lymphoplasmacytic infiltrate; cells were positive for cytokeratin and negative for lymphoma, melanoma, germ cell, and endocrine markers. Electron microscopy showed rare intermediate junctions and basal lamina. The nasopharyngeal tumor was poorly differentiated with areas of obvious squamous differentiation observed histologically, immunophenotypically, and ultrastructurally. Cytogenetic and fluorescent in situ hybridization studies were consistent with t(15;19)(q13;p13.1) in both cases. Both children received chemo- and radiotherapy. The first child died of disease after 36 weeks; autopsy revealed tumor in the larynx with spread to the skin/subcutis (neck and thorax) and lymph nodes (cervical, subcarinal, and pulmonary hilar). The second child developed widespread bony metastases and died of disease after 13 weeks.

CONCLUSIONS

In conjunction with previous reports, the authors' findings show that t(15;19) is part of a distinct clinicopathologic entity characterized by young age, midline carcinoma of the neck or upper thorax, and a rapidly fatal course. Female gender and superior vena cava syndrome are common. The histogenesis of these distinctive tumors is unknown. The authors' findings suggest origin in the upper airway, perhaps from submucosal glands.

Well-differentiated liposarcoma of the epiglottis

Liposarcomas of the larynx are very rare. A review of the English literature revealed only 28 published reports of tumours in this anatomical location. Diagnosis requires a high index of suspicion and careful histologic analysis. We present a case of a well-differentiated liposarcoma of the epiglottis, the tenth reported case at this laryngeal subsite. Initial biopsy specimens showed histological characteristics of a liposarcoma, which facilitated provision of optimal surgical treatment after careful analysis of published literature.

Graft-vs-host disease as a cause of enlargement of the epiglottis in an immunocompromised child

We report a rare case of dyspnea due to enlargement of the epiglottis in a severely immunocompromised patient. The child underwent a previous tracheostomy at another hospital because of respiratory distress under the diagnosis of acute epiglottitis. The patient was subsequently decannulated without incident. One year later, the child developed a new episode of dyspnea with inspiratory stridor. A new tracheostomy was neccessary, and a biopsy specimen of the enlarged epiglottis was taken to confirm the diagnosis of graft-vs-host disease. The therapeutic measures in these situations are discussed below, and a review of the current literature concerning the etiology and management of epiglottic enlargement is performed.

[Articulatory compensation after supracricoid partial laryngectomy with cricohyoidoepiglottopexy]

OBJECTIVES

The consequences of the modification of the glottis and the shortening of the vocal tract after supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP) were investigated prospectively on ten patients. An acoustic analysis of the transfer function of the vocal tract was performed by measuring the formant frequencies of the [a] and [i] vowels. The articulation compensatory mechanisms of the vocal tract were observed with cinefluoroscopy in order to evaluate the phonation and articulation constraints.

PATIENTS AND METHODS

Ten male patients were recorded before surgery and at six, 12 and 18 months after surgery. The results were compared with those of 10 male normal speakers having the same range of age. For the acoustic measures, we tracked the three first formant frequencies of the cardinal vowels [a] and [i], before and after surgery. Articulation investigation was performed with cinefluoroscopy for the vowels [a] and [i] uttered by two of the 10 patients.

RESULTS

For the [a] vowel, the acoustic analysis showed higher values for all three formants, related to the shortening of the vocal tract after surgery. For the [i] vowel, the lowering of the second formant frequencies after surgery was related to an articulatory compensation. Cinefluoroscopy confirmed the shortening of the vocal tract, the tongue-root retraction for voicing and the anterior position of the tip of the tongue for the [i] vowel.

CONCLUSIONS

The consequences of the shortening of the vocal tract after SCPL with CHEP can be evaluated, non invasively, by means of acoustic analysis. The understanding of the articulation compensatory mechanisms resulting from voicing constraints should help voice rehabilitation and improve oral communication in such patients.

Late lethal secondary hemorrhage after laser supraglottic laryngectomy

Since 1971, a number of articles have been published regarding the complications encountered with laser surgery of the larynx. Most investigations focus on complications such as accidental burns caused by the reflection of the laser beam, endotracheal explosion, special anesthesiologic problems, edema of the mucosa leading to airway obstruction, and abnormal scar formation with functional problems. Secondary hemorrhage has played a subordinate role, and in the few articles that have focused on it, cases requiring postoperative treatment have been reported only sporadically. All of these cases occurred within the first postoperative week, and no case resulting in the death of a patient was reported. We describe a patient in whom a lethal secondary hemorrhage occurred 10 days after a laser supraglottic laryngectomy. Because of the increase of laser applications in the treatment of laryngeal carcinoma, similar complications may be encountered. We comment on possible pathophysiological mechanisms and consequences.

Epiglottic tuberculosis: differential diagnosis and treatment. Case report and review of the literature

A case of a 40-year-old man with tuberculous involvement of the epiglottis suffering from unsuspected pulmonary tuberculosis is described. The laryngeal lesions were primarily considered to be highly suspicious for a neoplastic process rather than an infectious one. After diagnosis, the patient was treated according a standard protocol and followed up for a period of 2 years. He is still free of disease. The clinical presentation, diagnosis, pathological findings, and therapy of the condition are described. The differential diagnosis and management of epiglottic tuberculosis are reviewed and discussed. Even though these cases are rare, otorhinolaryngologists should keep in mind the possibility of tuberculosis in the differential diagnosis of laryngeal tumors, as the incidence of tuberculosis in developed countries is steadily increasing.

Airway rescue with the intubating laryngeal mask in a patient with an unexpectedly large epiglottic cyst

We report the successful use of the intubating laryngeal mask airway for rescue and intubation in an anaesthetised patient with an unexpectedly large epiglottic cyst. This case illustrates that airway rescue and intubation with the intubating laryngeal mask is possible and preoperative airway assessment does not always provide reliable information about airway management.

[Cricohyoidoepiglottopexy : deglutition in 44 cases]

The present work reviews the authors personal experience and applies a meta-analysis of the data in the literature (approximately 800 cases) to better focus on the opportunities and difficulties involved in the Majer-Piquet technique. Particular attention is focused on the problems involved in deglutition. The study involves 44 patients who underwent cricohyoidoepiglottopexy (CHEP) between 1989 and 1998. Given that surgical and rehabilitation techniques have been refined over the years, to better analyze the functional results, the data were separated into two subsequent periods. Of the 23 patients who underwent surgery between 1989 and 1992 (group I), 6 were benefited from bilateral preservation of the arytenoids while this was only possible in two of the 21 cases operated in the second period from 1993 to 1998 (group II). Functional rehabilitation was started earlier in the second group and was routinely monitored with digital viedeofluorography. The average recovery time was 34 days for group I and 27 days for group II. The tracheostomy closed in an average 91 days vs. the 13 days found by the meta-analysis of the literature. The authors normally leave the tracheostoma in place for a long time, even when closed with an easily removed plug, and only perform plastic surgery when the patient has shown stable deglutition for several weeks. The naso-gastric tube was removed from both groups of patients after an average 16 days while the review of the literature shows an average 21 days. On the whole the authors record good deglutition in 41 of the 44 cases (93.18%) with adequate deglutition in the remaining 3 cases. Likewise the literature reports good deglutition in 86.4% of the cases. The only difference found between the two groups of patients was a quicker recovery in the second group; there were no qualitative differences. The results are described and discussed. In conclusion, the present experience places CHEP in favorable light as long as the limits inherent to the method are recognized. However, these limitations relegate the technique to a "sporadic" role and the review of the literature appears to confirm this attitude.

Non-infectious epiglottitis in children: two cases report

Two young children who suffered from thermal injuries to the epiglottis after swallowing corrosive agent and hot water respectively. Findings, clinically and radiologically, in both children were similar to acute infectious epiglottitis. Both recovered quickly with close observation and parenteral antibiotics. Although Haemophilus influenzae type b (Hib) is the major pathogen of epiglottitis, in areas with low incidence of Hib infection and high vaccination rates, non-infectious epiglottic swelling should be considered first.

The ability of tumor volume to predict local control in surgically treated squamous cell carcinoma of the supraglottic larynx

PURPOSE

Pretreatment CT volumetric measurement of the primary tumor has been shown to be a predictor of local control in patients with laryngeal carcinoma treated with radiation therapy (RT) alone. A direct association has been demonstrated between tumor volume of supraglottic squamous cell carcinoma (SGSCCA) and local control. However, the association between tumor volume of SGSCCA and local control has not been investigated in patients treated surgically. The purpose of this study was to determine the relationship between SGSCCA tumor volume and local control in patients treated surgically.

MATERIALS AND METHODS

Primary site tumor volume was calculated from pretreatment CT studies in 37 laryngeal supraglottic carcinomas treated surgically. All patients had clinical follow-up for evidence of recurrent tumor along the surgical margins at the primary site for a minimum of 2 years after completion of treatment. Statistical analysis consisted of Mantel-Haenszel chi-square tests and Fisher's exact test.

RESULTS

Overall local control rate was 92% (33 of 37). Tumor volume was significantly associated with local control (p <. 05). Local control rate for tumors with volumes <16 cc was 94% (32 of 34) (p <.05).

CONCLUSIONS

Pretreatment CT volumetric analysis is useful for predicting local control in patients with SGSCCA carcinoma treated surgically.

Neoplastic invasion of laryngeal cartilage: radiologic diagnosis and therapeutic implications

Cross-sectional imaging plays an indispensable complementary role to endoscopy in the pretherapeutic workup of laryngeal and hypopharyngeal cancer. Both computed tomography and magnetic resonance imaging are suitable for the detection of neoplastic cartilage invasion. Although MRI, due to its high negative predictive value, is now generally considered to be the most suitable imaging method for pretherapeutic evaluation of cartilage invasion CT continues to be commonly performed in many centers for practical reasons. Recent studies have shown that CT may yield acceptable sensitivity for neoplastic invasion of laryngeal cartilage if the diagnostic criteria are selected and combined appropriately. False positive results are inevitable with both CT and MRI because reactive inflammation may lead to overestimation of neoplastic cartilage invasion.