Amyloidosis of the larynx

Risk factors for recurrence of laryngeal amyloidosis treated by microforceps and CO2 laser

INTRODUCTION

Laryngeal amyloidosis is a benign, slowly progressive disease. The factors affecting the recurrence of LA have not been studied before for the rarity and incomplete understanding of this disease. To investigate the risk factors for the laryngeal amyloidosis treated by microforceps or carbon dioxide laser under microlaryngoscope, a retrospective review was conducted.

MATERIALS AND METHODS

One hundred and four patients (42 male and 72 female, with an average age of 51.3 years) with laryngeal amyloidosis were identified. The cases were collected from January 1989 to May 2014 at the Eye, Ear, Nose, and Throat Hospital of Fudan University.

RESULTS

Seventy-five patients complained of hoarseness, 36 patients complained of hoarseness and dyspnea, and 3 patients complained of foreign body sensation. All patients underwent surgical removal of the amyloid deposits (via microforceps, CO₂ laser and tracheotomy). Thirty patients developed recurrences requiring further treatments. The duration from onset to the treatment and age affected the recurrence of laryngeal amyloidosis, the surgery method, stenotic degree and stenotic area of subglottic area and trachea did not affect the recurrence of the disease.

CONCLUSION

Early diagnosis and treatment of laryngeal amyloidosis may reduce the recurrence of the disease. Regular follow-up is necessary to find any recurrence.

Laryngeal Amyloidosis: Localized versus Systemic Disease and Update on Diagnosis and Therapy

The clinical and pathological characteristics, possibility of systemic disease, and effect of local therapy were studied in laryngeal amyloidosis. Records of all patients with localized laryngeal amyloidosis in a single tertiary referral center were examined retrospectively at diagnosis and after local therapy. Of 188 new patients with amyloidosis between 1990 and 2003, 5 patients had localized laryngeal amyloidosis. A sixth patient with localized laryngeal amyloidosis turned out to have systemic AL (immunocyte-derived) amyloidosis 8 years later. Free light chains were found in this patient, as well as in 1 of the other 5 patients. Amyloid interfering with laryngeal or airway function was removed during microlaryngoscopy with a carbon dioxide laser or cold endoscopic excision. The best results were seen when glottic deposits were removed by cold endoscopic excision, and supraglottic deposits by a carbon dioxide laser. Four patients had recurrent disease. A systematic workup, including measurement of free light chains, helps to rule out systemic disease.

Management of Upper Aerodigestive Tract Amyloidosis

Objectives:

The aim of this study was to discuss the treatment options for upper aerodigestive tract amyloidosis.

Methods:

Four patients with histologically confirmed amyloidosis were included in the study. All patients underwent surgical treatment. Three patients had laryngeal amyloidosis, and 1 patient had tonsillar amyloidosis.

Results:

Two of the cases of laryngeal amyloidosis were successfully treated with a combination of surgery and radiation therapy. One case of laryngeal amyloidosis was treated with surgery alone. The tonsillar amyloidosis was removed by tonsillectomy. None of the cases showed systemic involvement. Long-term follow-up of the patients showed no recurrence or evidence of systemic disease.

Conclusions:

Surgical resection is the primary treatment for patients with upper aerodigestive tract amyloidosis. Radiation therapy is especially effective in cases of recurrent amyloidosis with submucosal involvement. Pedunculated polypoid lesions may be treated with surgery alone, and in cases of recurrence, irradiation following the surgical removal should be considered. Tonsillectomy is usually sufficient for treating tonsillar amyloidosis.

KTP Laser in Laryngeal Amyloidosis: Five Cases with Review of Literature

To study the clinical presentation and review the options in the management of laryngeal amyloidosis. To study the efficacy of KTP 532 laser in the excision of laryngeal amyloidosis. Study was conducted in our department in a tertiary care hospital between Jan 2001 and Feb 2010. We report five patients who presented with hoarseness of voice and localized laryngeal lesions. The biopsy proven laryngeal amyloidosis lesions were excised microendoscopically using KTP 532 laser in three patients and other two patients were kept only on follow-up as they refused further surgery. The patients were evaluated for systemic amyloidosis. The average duration of follow up was 2.6 years (3 months 6 years). All the five patients in our study were asymptomatic with no evidence of recurrence at their last follow up. In our small case series, KTP 532 laser excision of the laryngeal amyloidosis had a favorable outcome. Long term follow up is required to rule out recurrence and systemic involvement.

Laryngeal plasmacytoma presenting as amyloid tumour: a case report

Laryngeal amyloidosis can be secondary to an underlying lymphoid neoplastic process and in view of this concept; the cases of localized laryngeal amyloidosis should be carefully examined and investigated for the presence of a lymphomatous process. The study design is case report. We report the case of a 64-year-old man with progressive hoarseness. A biopsy showed histological findings consistent with an extramedullary plasmacytoma associated with localized amyloidosis involving the right hemilarynx (ventricular band, arytenoids and true cord). Immunohistochemical studies showed that the tumour cells of the plasmacytoma were monoclonal (lambda-restricted). PCR analysis of the IgH gene demonstrated a clonal band confirming B-cell clonality. The amyloid deposits were also shown to be reactive with lambda immunoglobulin light chain, suggesting the pathogenetic relationship between the plasmacytoma and amyloid deposition in the larynx. There was no other evidence of malignancy or amyloidosis elsewhere. The majority of the cases reported of amyloid deposition with plasmacytoma, the lesions were found in the nasopharynx, in contrast to our case in which the lesions were sited in the larynx and with the peculiarity of being multiples. Moreover, amyloid and plasmacytoma were clearly delimitated and the amyloid tissue was more extensive than the tumour tissue. This case supports the concept that localized laryngeal amyloidosis may be a manifestation of low-grade B-cell neoplasms.

Laryngeal amyloidosis in 10 patients

OBJECTIVES

Review the location, symptoms, treatment, and outcomes in 10 consecutive laryngeal amyloid (LA) patients.

STUDY DESIGN

Pre and retrospective evaluation after treatment.

METHODS

Analysis of visual and phonatory pathology and detailed description of surgery.

RESULTS

Amyloid on the undersurface of both true vocal cords (TVCs) was found in two cases, uni- or bilaterally submucosally in the false vocal cords (FVCs) in eight cases, extending down into the lateral TVC in four cases, or on the undersurface of the TVCs as well in one case. The chief complaint was hoarseness and not shortness of breath. The amyloid was resected with a CO2 laser by way of microdirect laryngoscopy (MDL) on one side at a time to try to prevent anterior commissure scarring. Removal of most of the FVC improved the voice, but removal of the whole FVC to the inner thyroid perichondrium was found to be necessary to avoid recurrence from supraglottic deposits. Removal of at least 2 mm of the upper edge of a 3 to 4 mm thick submucosal deposit to the thyroarytenoid (TA) muscle along with the overlying mucosa on at least one side was necessary to improve hoarseness when amyloid was present on the undersurface of both TVCs. Partial regrowth occurred in a few months to years after partial removal. Seven patients had had one to seven prior removals. Any hard amyloid in the lateral TVC (floor of ventricle) as an inferior extension from FVC amyloid needed to be at least partially removed to avoid hoarseness from a convex vocal cord. The voice improved postoperatively in all patients. Follow-up after the first operation was 6 months to 16 years, with an average of 6.5 years. Four FVC patients required re-excision on the same side after the first operation, but none has required a third removal as of yet.

Amyloidosis of the upper aerodigestive tract

OBJECTIVES/HYPOTHESIS

To delineate the clinical and pathologic characteristics of upper aerodigestive tract amyloidosis with particular attention to laryngeal amyloidosis.

STUDY DESIGN

Retrospective chart review of patients with amyloidosis of Thomas Jefferson University and its affiliated hospitals.

MATERIAL AND METHODS

The charts of 16 patients with upper aerodigestive tract amyloidosis identified from the databases of the Thomas Jefferson University pathology department were reviewed and included in the study.

RESULTS

Sixteen patients (9 male and 7 female, with an average age of 49.8 years) with upper aerodigestive tract amyloidosis were identified. The most common site of amyloid involvement was the larynx. Consequently, patients most commonly presented with hoarseness (14 of 16). All patients underwent surgical removal of the amyloid deposits. Fourteen patients had primary localized amyloidosis. Two experienced systemic involvement. Seven of the 16 patients developed recurrences requiring further treatment.

CONCLUSIONS

Amyloidosis of the upper aerodigestive tract generally behaves as a benign, localized condition treatable by surgical resection. Regular follow-up with laryngoscopy is indicated for early diagnosis of recurrence, and multiple surgical procedures may be required to control symptoms.

Amyloidosis of the larynx: a clinicopathologic study of 11 cases

Laryngeal amyloidosis (LA) is uncommon and poorly understood, with limited long-term clinicopathologic and immunophenotypic studies in the literature. Eleven cases of LA were retrieved from the files of the Otorhinolaryngic-Head & Neck Tumor Registry from 1953 to 1990. The histology, histochemistry, immunohistochemistry, and follow-up were reviewed. All patients (three women and eight men) presented with hoarseness at an average age of 37.8 years. The lesions, polypoid or granular, measured an average of 1.6 cm and involved the true vocal cords only (n = 4), false vocal cord only (n = 1), or were transglottic (n = 6). An acellular, amorphous, eosinophilic material was present in the stroma, often accentuated around vessels and seromucous glands, which reacted positively with Congo red. A sparse lymphoplasmacytic infiltrate was present in all cases that demonstrated light chain restriction by immunohistochemistry in three cases (kappa = 2, lambda = 1). Serum and urine electrophoreses were negative in all patients. Treatment was limited to surgical excision, including a single laryngectomy. Six patients manifested either recurrent and/or multifocal/systemic disease: two patients with light chain restriction were dead with recurrent disease (mean, 11.1 years); two patients were dead with no evidence of disease (mean, 31.7 years); and two patients were alive, one with light chain restriction and recurrent and multifocal disease (41.6 years) and one with no evidence of disease after a single recurrence (43.4 years). The remaining five patients were either alive or had died with no evidence of disease an average of 32.4 years after diagnosis. No patient developed multiple myeloma or an overt B-cell lymphoma. LA is an uncommon indolent lesion that may be associated with multifocal disease (local or systemic). The presence of an associated monoclonal lymphoplasmacytic infiltrate and recurrent/multifocal disease in the respiratory or gastrointestinal tract of a few cases and the lack of development of a systemic plasma cell dyscrasia or overt systemic B-cell malignancy suggest that some LA may be the result of an immunocyte dyscrasia or tumor of mucosa-associated lymphoid tissue.

Anesthetic management of a patient with laryngeal amyloidosis

A 73-year-old woman who suffered from progressive hoarseness for 6 years and dysphagia without pain for 1 year presented with a soft tissue deposition on the posterior region of the vocal cords and narrowing in the subglottic area. Biopsy of this soft tissue and histological examination revealed laryngeal amyloidosis. A tracheostomy and partial removal of the amyloid were performed with general anesthesia. The airway was secured with a smaller diameter endotracheal tube, which was inserted atraumatically with Magill's forceps. The larynx is a rare site for amyloidosis. Laryngeal amyloidosis is fragile and hemorrhagic. Therefore, massive bleeding may occur during intubation. Anesthetists should take care in intubating the tracheas of these patients and be aware of other systemic diseases in laryngeal amyloidosis.

Primary amyloidosis presenting as a nasopharyngeal mass

Amyloid is defined as a pathologic proteinaceous substance which, when deposited between the cells of tissues and organs, leads to various clinical conditions. Immunohistochemistry has allowed for better classification and understanding of the pathophysiology of amyloidosis. In the upper aerodigestive tract, amyloidosis is a rare condition occurring most frequently in the larynx. We present the case of a 42-year-old woman with complete nasal obstruction due to primary nasopharyngeal amyloidosis. This represents the first reported case of primary nasopharyngeal amyloidosis containing both the lambda and kappa immunoglobulin light chains. The clinical and radiologic findings, as well as the management of primary amyloidosis of the upper aerodigestive tract, will be discussed. A review of the literature pertaining to nasal and nasopharyngeal amyloidosis will be presented.

Amyloidoma of the neck: case report and review of the literature

We present a case report of reactive amyloidoma of the neck in a patient with chronic calcaneal osteomyelitis. Localized deposits of amyloid may occur throughout the upper aerodigestive tract, but are rarely observed in the soft tissues of the neck. This is the first report in the literature of localized head and neck amyloidosis secondary to a chronic inflammatory or infectious process. A clinicopathologic review of amyloidosis is presented with particular attention to its head and neck manifestations.

Laryngeal amyloidosis in a child

A 14-year-old girl developed progressive hoarseness and breathing difficulty due to a mass in the subglottic larynx. A biopsy specimen obtained at direct laryngoscopy showed localized aggregates of amyloid. The lesion was excised completely with a carbon dioxide laser. This is the second case of laryngeal amyloidosis in a child reported in the English-language literature.

Primary amyloid tumors of the jejunum producing intestinal obstruction

The proximal jejunum, containing four separate amyloid tumors, was resected from a chronically constipated 71-year-old male exhibiting IgG lambda monoclonal gammopathy. Amyloid was deposited in the jejunal wall, mesentery and regional lymph nodes, but was not seen in gastric and rectal biopsy samples. Two years after surgery, the patient is well, but the monoclonal gammopathy persists.

Clinical implications of laryngeal amyloidosis

Four cases of laryngeal amyloidosis are reported. For the present three of these cases have to be considered as primary localized amyloidosis, the type usually found in the larynx. Amyloid in the larynx may be a manifestation of the generalized or secondary form, which has to be excluded in each case. Diagnosis is provided by various histochemical stainings of which Congo red is the most specific one. Electron microscopy can be very helpful. Treatment consists of local excision. Recurrence may become manifest after several years and long-term follow-up is recommended.

Oral amyloidosis: a late complication of multiple myeloma

Amyloidosis as a complication of multiple myeloma carries with it grave prognostic implications, and the median survival of myeloma patients following a diagnosis of amyloidosis is only 4 months. This article describes a patient who survived 6 years with kappa light chain myeloma, but only 4 months after the development of oral amyloid deposits. Oral amyloidosis may be clinically difficult to distinguish from fibrous, neurogenous, or salivary gland pathosis; however, histologic specimens stained with Congo red have a characteristic "apple green" appearance when examined microscopically with polarized light.