Arytenoid cartilage sclerosis: normal variations and clinical significance

PURPOSE: Our purpose was to determine the variation in location, distribution, and sex predilection of arytenoid cartilage sclerosis in a population of patients without laryngeal cancer as an aid to understanding the significance of this entity when seen in patients with laryngeal cancer. METHODS: One hundred CT examinations of patients of different ages and with no history of laryngeal cancer or radiation therapy were evaluated for the presence of arytenoid cartilage sclerosis. The arytenoid cartilage was subdivided into three regions: superior process, body, and vocal process. Each region was assessed on each side separately on bone window scans. RESULTS: Arytenoid cartilage sclerosis was seen in 16% (n = 16) of the patients. Sclerosis was most common in the body (n = 12) and least common in the true vocal process (n = 2); the left side was the preferred location for all three regions. In 50% of the patients, at least two regions were affected. Eighty-one percent of sclerotic arytenoid cartilage was seen in women. CONCLUSION: Knowledge of the frequency and distribution of arytenoid cartilage sclerosis as a normal variant can aid in determining the risk of arytenoid cartilage involvement in patients with laryngeal cancer.     

Combined chemotherapy with low-dose cisplatin, tegafur and uracil in a case with neck recurrence of laryngeal cancer

The patient was a 60-year-old man with progressive neck recurrence of laryngeal squamous cell carcinoma. As a previous treatment, he had undergone irradiation (primary: 60 Gy; neck: 45 Gy) after two cycles of neoadjuvant chemotherapy (cisplatin 100 mg/m2 daily; day 1:5-fluorouracil 1,000 mg/m2 daily; day 1-5) and planned neck dissection. For a neck recurrence, he had received five cycles of low-dose cisplatin (5 mg/body daily: day 1-5) with tegafur and uracil (600 mg/body daily: day 1-7) every week. As an outpatient, he then received ten cycles of low-dose cisplatin (10 mg/body daily: day 3, 6) with tegafur and uracil (600 mg/body daily: day 1-7) every week. The size of the tumor did not decrease with the above chemotherapy, but no remarkable growth of the cancer was seen, and no toxic effect of the chemotherapy was observed. He continued his job for 30 weeks just as before he had fallen sick. Chemotherapy of low-dose cisplatin with tegafur and uracil was suggested to be useful for the patient with recurrent laryngeal squamous cell carcinoma.     

Laryngeal foreign body: an unusual complication of percutaneous tracheostomy

Impaction of a foreign body in the larynx is a serious event. While inhaled foreign bodies may occasionally impact in the larynx especially in children, a laryngeal foreign body as a complication of percutaneous tracheostomy has not been reported in the literature. We describe the case of a fragment of a Seldinger wire retained in the larynx for two years following a percutaneous tracheostomy and review the literature on the complications of this procedure.     

Physical-mechanical effects of Nd:YAG laser on the surface of sound dental enamel

We present our experience with 55 children in which we performed flexible fiberoptic bronchoscopy (FFB) using an Olympus BF3C20 instrument and by using sedation and local anaesthesia or laryngeal mask airway. Indications for performing this procedure were stridor, opportunist or recurrent pneumonia, persistent atelectasis, a suspected foreign body, confirmation of endobronchial tuberculosis and evaluation of tracheostomy. In 70% of the cases, the diagnosis was made by the FFB and 14 cases were normal. One child with severe hypoxia presented respiratory arrest and need intubation. Our results suggest that FFB is safe, has advantages over rigid bronchoscopy, avoids general anaesthetic and with laryngeal mask airway is possible to perform in patients of every age.     

Bifid epiglottis: a rare laryngeal anomaly

Two cases of bifid epiglottis are presented: one with an associated laryngeal cyst and another with an associated cricoid stenosis. The occurrence of multiple laryngeal anomalies in association with bifid epiglottis has not previously been described. The occurrence of an extra digit is noted to be statistically significant both in the current series and in a review of the literature. A brief review of the embryologic classification and staging by the Carnegie System, and the correlation of the time sequence of development of the epiglottis is presented. No correlation is made as to the mechanism of the origin of this laryngeal anomaly, as adequate embryologic knowledge of the development of the pharynx is not available at this time.     

Environmental factors in cancer of the larynx: a second look

During a retrospective case-control study of recent laryngeal cancer patients, several associated factors were studied to determine possible changes in the epidemiology of laryngeal cancer between 1956 and 1974. The large sex difference noted in the early survey (male: female ratio of 14.9:1) diminished considerably in the present sample (4.6:1) because more women are cigarette smokers in the cancer age group today than was the case 20 years ago. Laryngeal cancer patients tended to be less educated than the controls and included a smaller proportion of Jews and more Catholics than the control group. The risk for developing laryngeal cnacer was considerably lower for exsmokers and long-term (10+ years) filter cigarette smokers as compared with non-filter smokers. At each level of alcohol consumption, the risk increased as exposure to tobacco increased. Occupations associated with wood exposure were found to affect the development of laryngeal cancer, independently of smoking status. Future studies should include an extensive study of nutritional deficiencies associated with alcoholism to determine if a correlation exists between such deficiencies, socioeconomic status, and an increased risk of laryngeal cnacer.     

The mechanisms of the stimulating effect of tissue basophils on the reparative processes in inflammation]

The authors have carried out the immunoassay on 68 patients with laryngeal carcinoma in order to investigate the relationship between the occurrence and development of the tumour and the body immune state by using the methods of R1D, APAAP and LDH. The results showed that, in comparison with the normal group, CD3+, CD4+ cell and NK cell activity were much lower (P < 0.01), CD8+ cell slightly increased (P > 0.05). IgG, IgA and IgM were also lower (P < 0.05). It indicates that the lower level of cellular immunity, the descent of the ratio of CD4+/CD8+ and the condition which suppresses the body immune system are the interior factors which make the laryngeal carcinoma happening and developing easily. With the development of tumor, the increase of various suppressor factors and the immune system suppressed further the tumor can spread and shift much more easily.     

Anatomy of the human internal superior laryngeal nerve

The mucosa of the larynx contains one of the most dense concentrations of sensory receptors in the human body. This sensitivity is used for reflexes that protect the lungs, and even momentary loss of this function is followed rapidly by life-threatening pneumonia. The internal superior laryngeal nerve (ISLN) supplies the innervation to this area, and, to date, the distribution and branching pattern of this nerve is unknown. Five adult human larynges were processed by using Sihler's stain, a technique that clears soft tissue while counterstaining nerves. The whole-mount specimens were then dissected to demonstrate the branching of the ISLN from its main trunk down to the level of terminal axons. The human ISLN is divided into three divisions: The superior division supplies mainly the mucosa of the laryngeal surface of the epiglottis; the middle division supplies the mucosa of the true and false vocal folds and the aryepiglottic fold; and the inferior division supplies the mucosa of the arytenoid region, subglottis, anterior wall of the hypopharynx, and upper esophageal sphincter. Several dense sensory plexi that cross the midline were seen on the laryngeal surface of the epiglottis and arytenoid region. The human ISLN also appears to supply motor innervation to the interarytenoid (IA) muscle. A detailed map is presented of the distribution of the ISLN within the human larynx. The areas seen to receive the greatest innervation are the same areas that have been shown by physiological experiments to be the most sensate: the laryngeal surface of the epiglottis, the false and true vocal folds, and the arytenoid region. The observation that the human ISLN appears to supply motor innervation to the IA muscle is contrary to current concepts of the ISLN as a purely sensory nerve. These findings are relevant to understanding how the laryngeal protective reflexes work during activities like swallowing. The nerve maps can be used to guide surgical attempts to reinnervate the laryngeal mucosa when sensation is lost due to neurological disease.     

Thyroglossal duct cyst causing airway obstruction in an adult

Thyroglossal duct cysts, though not uncommon, rarely present with evidence of laryngeal compromise. The case presented is one of the very few cases with documented laryngeal invasion reported in the English language. Of clinical significance is the patient's presentation with laryngeal symptoms of choking and dysphonia in the presence of a small anterior cervical mass. While the thyroglossal duct cyst usually presents as an asymptomatic anterior neck mass, this case illustrates the importance of considering a thyroglossal duct cyst in any patient with airway compromise in the absence of a neck mass.     

A comparison among different inversion methods for multi-exponential NMR relaxation data

With the object to disclose an association between laryngeal papillomatosis and laryngeal carcinoma, we reviewed 102 patients with laryngeal papillomatosis treated between 1950 and 1979. Seven cases of laryngeal carcinomas were recorded and 1 patient with spread of papilloma to the bronchial tree developed a bronchial carcinoma. The time between onset of papilloma and diagnosis of carcinoma was 4-55 years (mean 24 years). For laryngeal carcinoma the ratio of observed to expected cases was 88. Of the 8 patients developing respiratory tract carcinoma, 2 had received treatment with radiation and 2 had been treated with Bleomycin. Four of these 8 patients were known smokers. This study shows that papillomatosis is more often associated with laryngeal carcinoma than previously reported. It appears, however, that laryngeal papillomas alone seldom induce carcinomas. Apart from irradiation and smoking, Bleomycin could be an important co-factor.     

Laryngeal atresia or stenosis presenting as second-trimester fetal ascites--diagnosis and pathology in three independent cases

Congenital atresia of the larynx is a rare abnormality. We describe three cases where prenatal diagnosis during the second trimester showed massive abdominal fetal ascites and at post-mortem, laryngeal atresia was identified in two cases, and severe laryngeal stenosis in the third. All were associated with pulmonary hyperplasia. No additional abnormalities were found in other systems. Overdistended lung tissue and ascites are resultant from aberrant laryngeal growth; laryngeal anomalies are a cause of isolated fetal ascites. The association of ascites and voluminous lungs should arouse suspicion of laryngeal atresia and should be an indication for careful pathological study of the fetal larynx.     

Ease of insertion of the laryngeal mask airway by inexperienced personnel when using an introducer

The Portex introducer for the laryngeal mask airway was designed as an aid to successful insertion, acting as an idealised 'artificial hard palate' to guide the tip of the laryngeal mask into the correct position. A number of authors have investigated laryngeal mask insertion by unskilled personnel in certain situations, one example being nurses during in-hospital cardiopulmonary resuscitation. We investigated whether the introducer had any effect on the incidence of first-time successful LMA placement by unskilled personnel. These were nonanaesthetist doctors, randomly assigned to have one attempt at LMA insertion in an anaesthetised patient, with and without the introducer. In 44 patients with the LMA being inserted according to the manufacturer's instructions, there was a 68% success rate (14 failures). In 45 patients with the LMA being inserted with the aid of a Portex introducer, there was a 96% success rate (two failures). This was a highly significant improvement (p < 0.001).     

The site of airway irritation during induction of anaesthesia

The aim of this investigation was to study the role of the nasal airway in mediating upper airway reflexes during induction of anaesthesia when the commonly used irritant inhalational anaesthetic agent enflurane is used. In a prospective randomised study, 40 ASA 1 & 2 day-case patients undergoing body surface surgery were recruited. Following intravenous induction using propofol, 20 patients received enflurane administered via a laryngeal mask airway (LMA), the anaesthetic vapour therefore bypassing the nasal airway. In the other group, 20 patients received enflurane anaesthesia administered using a face mask, the nasal airway therefore being exposed to inhalation anaesthetic. We were unable to demonstrate any significant (p < 0.05) differences between the two groups in relation to upper airway complications (cough, breath holding, laryngeal spasm, bronchospasm and excitement). Previous work has identified the nose as a possible important reflexogenic site for upper airway reflexes in humans during anaesthesia. We have been unable to demonstrate any difference in upper airway complications when the nasal airway was included or excluded from exposure to irritant anaesthetic vapours, when administered in a clinical setting.     

Laryngocele: clinical and therapeutic study of 60 cases

Sixty patients with laryngocele were diagnosed in the last seven years: 25 of them without previous laryngeal pathology (group A) and the rest 35 with laryngeal or pharyngeal cancer (group B). The laryngocele was unilateral in the majority of the 25 patients of group A (68%). The internal laryngoceles were the most common type (63%). The initial symptom was hoarseness in 56% of these patients and 20% developed, in their evolution, an acute respiratory distress. The diagnosis was clinical in 16 patients and radiological in the rest. Endoscopically marsupialization with laser-CO2 was performed to remove internal laryngoceles. The mixed and external laryngoceles were completely removed via an external cervical approach without the need to perform any thyrotomy. The diagnosis was radiological by CT in the 35 patients of the group B. In 30 of them the CT was performed to evaluate the local extension of the laryngeal or pharyngeal cancer before its treatment. Supraglottic carcinoma was the most common laryngeal tumor (50%). The anatomic relationship between laryngocele and laryngeal cancer was ipsilateral to each other only in 50% of the patients. In the other 5 patients, no laryngocele was found in the radiological study previous to the treatment of the laryngeal or pharyngeal cancer. The diagnosis was made after chemotherapy and/or radiotherapy treatment.     

Laryngeal involvement by systemic lupus erythematosus

Indirect laryngeal photography with the rod laryngeal telescope provided an excellent method of documenting evolution of the laryngeal pathology in two cases of systemic lupus erythematosus. This disease may have mucosal or serosal manifestations in the larynx. Currently, management of mucosal disease includes acute and long-term corticosteroid therapy, and should the airway become compromised by edema or scarring, then tracheostomy and specific laryngeal reconstruction during a quiescent period in the disease is required. The course of serosal involvement, notably cricoarytenoid arthritis, may be followed by observing vocal cord motion sequentially and assessing the degree of throat pain. Oral corticosteroids in maintenance dosages is the accepted modality of treatment, with dosage being boosted for exacerbations.     

A systems analysis approach to medical error

Using decerebrate frogs (Rana catesbeiana), we investigated the role of vagal and laryngeal sensory feedback in controlling motor activation of the larynx. Vagal and laryngeal nerve afferents were activated by electrical stimulation of the intact vagal and laryngeal nerves. Pulmonary afferents were activated by lung inflation. Reflex responses were recorded by measuring efferent activity in the laryngeal branch of the vagus (Xl) and changes in glottal aperture. Two glottic closure reflexes were identified, one evoked by lung inflation or electrical stimulation of the main branch of the vagus (Xm), and the other by electrical stimulation of Xl. Lung inflation evoked a decrementing burst of Xl efferent activity and electrical stimulation of Xm resulted in a brief burst of Xl action potentials. Electrical stimulation of Xl evoked a triphasic mechanical response, an abrupt glottal constriction followed by glottal dilatation followed by a long-lasting glottal constriction. The first phase was inferred to be a direct (nonreflex) response to the stimulus, whereas the second and third represent reflex responses to the activation of laryngeal afferents. Intracellular recordings of membrane potential of vagal motoneurons of lung and nonlung types revealed EPSPs in both types of neurons evoked by stimulation of Xm or Xl, indicating activation of glottal dilator and constrictor motoneurons. In summary, we have identified two novel reflexes producing glottic closure, one stimulated by activation of pulmonary receptors and the other by laryngeal receptors. The former may be part of an inspiratory terminating reflex and the latter may represent an airway protective reflex.     

Laryngeal survey in glyphosate intoxication: a pathophysiological investigation

Respiratory aspiration is a serious potential complication of glyphosate-surfactant herbicide intoxication. From October 1, 1992 to June 30, 1996, we performed laryngeal evaluations in 53 cases to investigate the possible pathophysiological mechanism of glyphosate intoxication. There were 36 cases with significant laryngeal injury. The blood WBC count were significantly higher and the hospital stays were significantly longer in patients with laryngeal injury, when compared with patients with no laryngeal injury (Student t-test, P < 0.005). Laryngeal injury was strongly correlated with aspiration pneumonitis (mean 2 = 4.449, P < 0.05). We concluded that laryngeal injury may be the major cause of aspiration that leads to some degree of morbidity and mortality, following concentrated glyphosate-surfactant herbicide intoxication. Laryngeal survey may be indicated in cases of glyphosate-surfactant intoxication, to evaluate the severity of mucosal injury, and to apply adequate supportive management as early as possible to prevent from aspiration complications and even mortality.     

Inhalation of foreign bodies in children. Report of 500 cases

Inhalation of foreign bodies is a major cause of accidental death during childhood. Aspiration of foreign bodies is common in children aged 1 to 3 years, especially in boys. A past history of foreign body aspiration is itself an indication for bronchoscopic examination of the airways, because some children with aspirated foreign bodies are without symptoms and chest x-ray films may not show abnormalities. Bronchoscopic removal of the foreign bodies requires close communication between the anesthesiologist and the endoscopist. Forgotten foreign bodies in the airways cause chronic pulmonary infections, allergic asthma, bronchiectatic changes, and lung abscess. Foreign bodies that cannot be grasped by bronchoscopic forceps should be removed by thoracotomy and bronchotomy. This report describes our experience in 500 children with suspected foreign body inhalation. We routinely use prednisolone, 1 to 2 mg. per kilogram, and nebulization just after bronchoscopic examination of the airways. This medication greatly diminishes the rate of postbronchoscopic complications such as laryngeal edema, which require tracheostomy. In our series of 500 case, the incidence of postbronchoscopic tracheostomy is 1.4 per cent and the total mortality rate is 1.8 per cent.     

Vertical infraclavicular brachial-plexus blockade. A clinical study of reliability of a new method for plexus anesthesia of the upper extremity

BACKGROUND: Historically, total laryngectomy with voice-prosthesis insertion and near-total laryngectomy were the surgical options advocated for advanced supraglottic and transglottic tumors classified as T3-T4. METHODS: The present retrospective study reviewed our experience with neo-adjuvant chemotherapy and supracricoid partial laryngectomy with cricohyoidopexy (SCPL-CHP) in a series of 60 patients with an isolated, untreated, advanced supraglottic/transglottic invasive squamous cell carcinoma classified as T3-T4. RESULTS: The Kaplan-Meier 5-year actuarial survival, local failure, nodal failure, and distant metastasis estimates were 72.7%, 8.3%, 9.2%, and 9.8%, respectively. Survival was significantly reduced in patients with nodal failure (p = .001) and distant metastasis (p = .007). Overall, a 91.7% laryngeal preservation rate and a 98.3% local control rate were achieved. CONCLUSION: Our report was a retrospective analysis and did not present a control group exclusively managed with SCPL-CHP. Therefore, we were unable to demonstrate that the use of neo-adjuvant chemotherapy prior to SCPL-CHP allowed for an increase in local control, laryngeal preservation, and survival. However, the use of neo-adjuvant chemotherapy allowed for remobilization of a fixed arytenoid cartilage in 10 patients who thus became amenable to SCPL-CHP. The key role of neo-adjuvant chemotherapy in this series was as a prognostic indicator for suitability for SCPL-CHP in the case of supraglottic-transglottic tumor with arytenoid cartilage fixation. Our data also supported the notion that SCPL-CHP is a valid alternative to total laryngectomy with voice prosthesis insertion and near-total laryngectomy in selected patients with a previously untreated supraglottic/transglottic invasive squamous cell carcinoma classified as T3-T4. Furthermore, the successful use (in terms of surgical outcome, laryngeal preservation, and survival) of SCPL-CHP after neo-adjuvant chemotherapy suggested that laryngeal organ-preservation strategies, in advanced endolaryngeal transglottic and/or supraglottic invasive squamous cell carcinoma, should not be limited to the use of laryngeal radiotherapy after neo-adjuvant chemotherapy.