Subglottic paraganglioma

Pitfalls in the management of subglottic paragangliomas at unusual location: a case report and literature review

Background

Subglottic paragangliomas (PGs) are exceptionally rare and unpredictable, occasionally presenting at an atypical location. There are three different clinical forms of subglottic PGs: intraluminal (tracheal PGs), extraluminal (thyroid PGs) and the mixed type (both intraluminal and extraluminal, mixed-subglottic PGs). These tumors are usually misdiagnosed as other relatively common primary thyroid or laryngotracheal tumors, and the treatment is troublesome.

Case presentation

A 22-year-old male patient with subglottic PGs has been successively misdiagnosed as thyroid tumors and subglottic hemangiomas, and lastly underwent local extended lumpectomy and laryngotracheal reconstruction with a pedicled thoracoacromial artery perforator flap (PTAPF). The patient was decannulated successfully after the second-stage tracheal reconstruction with a local flap, and no evidence of local recurrence and distant metastasis of the tumor until now.

Conclusion

Subglottic PGs can be easily misdiagnosed as laryngotracheal or thyroid tumors when presented at an atypical location. It is essential for otolaryngologists and head and neck surgeons to remain vigilant against these tumors. If the tumor is not diagnosed or removed completely, patients may encounter a risk of lethal paroxysm, which is incredibly troublesome.

Laryngeal paraganglioma: a rare clinical entity managed by supraselective embolization and lateral pharygotomy

Laryngeal paragangliomas are benign slow growing tumors with symptoms resembling squamous cell carcinoma. Hoarseness or dysphasia are the commonest presenting symptoms and usually it presents as an submucosal mass on laryngoscopy. Ninety percentage of these tumors occur in the supraglottic larynx and the rest in the glottis and the subglottic region. Functional activity is seen in a few (2.9 %), none are associated with paraneoplastic syndromes. A 35-year-old male presented to us with hoarseness of voice since 4 months duration. Contrast arteriography demonstrated that the left superior thyroid artery supplied >80 % of the blood supply to the laryngeal mass. Supraselective embolization was done from the right femorals under local anaesthesia and sedation which was uneventfull. The tumor was excised from lateral pharyngotomy approach with an partial laryngectomy procedure. Microscopy and immune-histochemistry confirmed it to be paraganglioma. Complete surgical resection or partial laryngectomy with meticulous dissection of surrounding tissues and preservation of neurovascular structures gives an excellent prognosis as far as oncological clearance is concerned. Malignant paragangliomas of the larynx are rare and an major meta-analysis is necessary to provide a true biological behaviour of this tumor.

Laryngeal paraganglioma in an irradiated neck

Objective:

We present the first reported case of a paraganglioma of the larynx occurring concurrently with squamous cell carcinoma in an irradiated neck.

Method:

We present a case report and a literature review of paraganglioma of the larynx.

Case report:

A 78-year-old woman was found to have a mass on the laryngeal surface of the epiglottis and non-functioning larynx, four months after radical radiotherapy for biopsy-proven squamous cell carcinoma. Repeated positron emission tomography computed tomography was highly suggestive of residual malignancy. Given these findings, and the fact that the patient was aspirating, she was treated with total laryngectomy, and was found to have a paraganglioma of the larynx.

Conclusion:

This is the first report of such a case. Its importance is three-fold in that it demonstrates: the coexistence of paraganglioma and squamous cell carcinoma; the difficulties that can be encountered in the diagnosis; and the use of radiotherapy in the treatment of paraganglioma.

Neuroendocrine neoplasms of the larynx: an overview

Neuroendocrine neoplasms of the larynx are rare but are the most common nonsquamous tumors of this organ. In the past, there has been considerable confusion about the nature and classification of these neoplasms, but the current consensus is that there are 4 different types of laryngeal neuroendocrine tumors composed of paraganglioma, typical carcinoid, atypical carcinoid tumor, and small cell neuroendocrine carcinoma. Carcinoids and small cell neuroendocrine carcinomas are epithelial neoplasms, whereas paragangliomas are of neural origin. Diagnosis is based primarily on light microscopy and confirmed by immunohistochemistry and electron microscopy. Precise diagnosis is essential because the natural history, treatment, and prognosis vary widely for the different neoplastic categories. Typical carcinoids are very rare and are treated by wide local excision, usually partial laryngectomy, without elective neck dissection. Atypical carcinoid tumors are more common and more aggressive. They are treated by partial or total laryngectomy with elective or therapeutic neck dissection. Adjuvant chemo/radiotherapy may be of benefit in some cases. Small cell neuroendocrine carcinomas are highly aggressive and should be considered disseminated at initial diagnosis. The treatment is by irradiation and chemotherapy as surgery has proven to be of a little benefit. Paragangliomas are treated by local excision or partial laryngectomy. It is difficult to determine the valid survival statistics for typical carcinoids because of their rarity and confusion in the literature with their atypical counterparts. They have a greater tendency to metastasize, and thus a worse prognosis than was previously believed. Atypical carcinoid tumors have a 5-year survival rate of approximately 50%, which decreases with time. The prognosis of small cell neuroendocrine carcinoma of the larynx is dismal, with 5-year survival rates of 5%. The biological behavior of laryngeal paraganglioma is generally benign and the prognosis is excellent.

Neuroendocrine neoplasms of the larynx: Advances in identification, understanding, and management

While 85-90% of laryngeal malignancies prove to be squamous carcinomas, the second most common tumour type found in the laryngeal region will prove to be a member of the family of neuroendocrine tumours. Laryngeal carcinoid tumours have a capacity for metastasis, and so are more aggressive tumours than their light microscopic features might imply--5-year survival rates are in the vicinity of 50%. Laryngeal atypical carcinoid tumours are lesions with a well-recognized capacity for local recurrence as well as metastasis, with a 5-year survival of just under 50%. Laryngeal small cell neuroendocrine carcinomas are particularly aggressive tumours, with a 5-year survival of no more than 5-10%. Laryngeal paragangliomas are lesions without any real capacity for metastasizing. Surgical excision is the mainstay of treatment of carcinoid tumours, atypical carcinoid tumours, and paragangliomas. Small cell neuroendocrine carcinomas are chiefly treated by way of radiation and chemotherapy; the role of adjuvant therapy in the treatment of atypical carcinoid tumours remains to be established.

Laryngeal paraganglioma: an updated critical review

Laryngeal paragangliomas are rare submucosal lesions that arise from paraganglion cells located in the false vocal fold and subglottic larynx. To date, 76 recognized cases have been reported in the world literature. Symptoms arise when the lesions become large enough to impair function. Supraglottic paragangliomas cause hoarseness and deglutition disorders, whereas subglottic tumors become symptomatic when they obstruct the airway. Evaluation of these tumors includes obtaining a complete history. Familial paragangliomas and hypertension should be sought but are rarely, if ever, associated with laryngeal paragangliomas. MRI can detect these lesions and permit characterization of the vascularity of the lesion. Adding 111In pentetreotide scanning can distinguish neuroendocrine tumors from other submucosal laryngeal lesions, making the preoperative diagnosis clearer and obviating the need for biopsy. The biggest dilemma regarding laryngeal paragangliomas is making the correct pathologic distinction between paraganglioma, typical carcinoid, atypical carcinoid and medullary thyroid cancer. Immunohistochemical markers, supplementing standard histopathologic evaluation, can distinguish paragangliomas from the aforementioned tumors. This distinction is critical as the prognosis for treated paragangliomas is excellent compared to that for other neuroendocrine neoplasms. Almost all alleged malignant paragangliomas of the larynx are in reality atypical carcinoid tumors that have been misdiagnosed. Treatment should always comprise excision. Thyrotomy has the best chance of achieving a sustained cure without damaging phonation or deglutition. Laser excision has been used successfully but there is no great experience with this modality. Surgery is preferable to radiation for paragangliomas in all locations but especially so in the larynx, due to issues such as swelling, airway protection and destruction of cartilage. With increased clinical suspicion and the use of modern imaging techniques, laryngeal paragangliomas should be routinely diagnosed and treated without loss of laryngeal functions.

Diagnosis and treatment of supraglottic laryngeal paraganglioma: report of a case

BACKGROUND

Paragangliomas of the larynx are unusual tumors that are seen as a vascular submucosal mass. These usually are seen in the supraglottic larynx but have also been found in the subglottis. This is the only laryngeal neuroendocrine tumor with a female predilection. It is important that paragangliomas be differentiated from other neuroendocrine tumors of the larynx, including atypical carcinoid, because of differing treatment modalities.

METHODS

We present the clinical, radiologic, and pathologic findings of a supraglottic laryngeal paraganglioma seen in a 50-year-old woman with a 6-month history of slowly progressive hoarseness.

RESULTS

The tumor was successfully approached by means of a midline laryngofissure with mucosal preservation. The patient remains disease free 24 months after surgery.

CONCLUSIONS

Preoperative CT and angiography are useful in making the diagnosis of paraganglioma before surgical intervention. Complete excision through an external mucosa-sparing approach is the treatment of choice. Distinguishing laryngeal paraganglioma from other neuroendocrine tumors can be difficult. Immunohistochemistry is an important tool for the correct pathologic diagnosis.

Subglottic laryngeal paraganglioma

OBJECTIVES

To review the clinical and pathological picture of laryngeal paragangliomas and compare laryngeal paragangliomas with the three other types of laryngeal neuroendocrine neoplasms.

STUDY DESIGN

The study presents a case review of a patient with a subglottic laryngeal paraganglioma treated at our institution, with a literature review of the laryngeal neuroendocrine neoplasms. Included is a review of all four neuroendocrine neoplasms, taking a close look at a comparison between laryngeal paragangliomas and atypical carcinoids tumors. All cases of subglottic laryngeal paragangliomas reported in the literature were also compiled and tabulated.

METHODS

The patient's record was reviewed for age, symptomatology, workup, and surgical procedures performed.

RESULTS

The patient was disease free 36 months after undergoing a tracheostomy for airway control, followed by a cricoid split for complete excision of the tumor.

CONCLUSIONS

It is important to differentiate among the four laryngeal neuroendocrine neoplasms, especially between atypical carcinoids and paragangliomas. Each tumor requires different treatments, with the former requiring a more aggressive approach. Paragangliomas must be completely excised to prevent their recurrence, and this approach should be considered a curative treatment. In addition, the immunohistochemical battery is of paramount importance in obtaining the correct pathological diagnosis.

Neuroendocrine neoplasms of the larynx: diagnosis, treatment and prognosis

The authors discuss the terminology, classification, diagnosis, treatment and prognosis of neuroendocrine neoplasms of the larynx.

Relapsing paraganglioma of the inferior laryngeal paraganglion: case report and review of the literature

BACKGROUND

Laryngeal paragangliomas are very rare neoplasms derived from the superior or inferior laryngeal paraganglia. The paragangliomas of the inferior laryngeal paraganglion, depending on their anatomic variability, can give rise to two different clinical expressions of the same process, namely the so-called thyroid paragangliomas and the inferior laryngeal or subglottic paragangliomas.

METHODS

We present a case for which we have not found any previous descriptions of a cervical and subglottictracheal relapse of a thyroid paraganglioma removed 3 years earlier. We review the literature.

RESULTS

We have found a total of 22 paragangliomas of the inferior laryngeal paraganglia, 23 including our case.

CONCLUSIONS

Thyroid paragangliomas and inferior laryngeal or subglottic paragangliomas should be included under the term "paragangliomas" of the inferior laryngeal paraganglion. These tumors are slow growing, benign, hypervascular, and much more common in middle-aged women. Immunohistochemistry is essential for its diagnosis. Open, conservative surgery is the treatment of choice.

Paragangliomas: classification, pathology, and differential diagnosis

This article discusses the paraganglion system and extra-adrenal paragangliomas. In particular, the clinicopathologic, immunohistochemical, and ultrastructural features of paragangliomas and neuroendocrine neoplasms of the larynx are presented with a discussion of the differential diagnosis.

Laryngeal and sinonasal paragangliomas

Laryngeal paragangliomas are classified as supraglottic and infraglottic. This article defines each type of paraganglioma, discusses the clinical features and diagnoses, and covers the surgical management. This article also addresses sinonasal paragangliomas, including their clinical features, diagnosis, and treatment.

A review of neuroendocrine neoplasms of the larynx: update on diagnosis and treatment

Neuroendocrine neoplasms of the larynx have been divided into those of epithelial or neural origin. The latter consist of paragangliomas while the epithelial origin group can be divided into the typical and atypical carcinoids and small cell neuroendocrine carcinomata, the latter consisting of the oat cell type, the intermediate cell type and the combined cell type. There are now over 500 cases of neuroendocrine neoplasms of the larynx in the literature. The diagnosis is primarily based on light microscopy, and, in some instances, it may be supported by special histochemical studies. It should be confirmed by immunocytochemical and/or ultrastructural investigation. The different biological behaviour of neuroendocrine neoplasms of the larynx makes a specific diagnosis of paramount importance, since treatment depends on diagnostic accuracy. Typical carcinoid is an extremely rare lesion. It is treated preferably by conservative surgery; elective neck dissection is not necessary because of the lack of lymph node metastases at diagnosis. Chemotherapy and/or radiotherapy have not been effective in the limited number of patients treated thus far. Prognosis is excellent with cure following surgery. Atypical carcinoid is the most frequent non-squamous carcinoma of the larynx. The mainstay of treatment is surgery. Elective neck dissection should be performed because of the high likelihood of cervical lymph node metastases. Primary radiation therapy with adjuvant chemotherapy is not indicated. The survival rate is 48 per cent at five years and 30 per cent at 10 years. Although the larynx is one of its most common extrapulmonary sites, small cell neuroendocrine carcinoma is still a rare tumour. Surgical results for this tumour have been disappointing and is reserved for cases of local relapse with no evidence of metastasis. Chemotherapy and radiotherapy currently appear to offer the least disabling and most effective forms of therapy. The two- and five-year survival rates are 16 per cent and five per cent, respectively. Paraneoplastic syndromes have occasionally been reported in association with carcinoid tumours (typical and atypical) and small cell neuroendocrine carcinoma. There have been also rare reports of an elevated neuropeptide serum level. Paraganglioma is the only laryngeal neuroendocrine neoplasm with a female preponderance (3:1). Confusion with atypical carcinoid has led to incorrect diagnosis and inappropriate classification schemes, erroneously suggesting that laryngeal paraganglioma has the potential for aggressive behaviour. Conservative surgery represents the treatment of choice; elective neck dissection is not necessary, and the prognosis is excellent.