Laryngeal Involvement Research Articles

Lymphatic Malformations of the Airway

To characterize the anatomic distribution of lymphatic malformations of the upper airway. Case series with chart review. Tertiary care referral center specializing in the diagnosis and treatment of vascular anomalies. A 7-year (2004-2011) retrospective chart review of patients with lymphatic malformations was performed at a tertiary care referral center. Patients with airway lymphatic malformations were identified. The anatomic distribution of lymphatic malformations within the airway was reviewed. A total of 141 patients with lymphatic malformations of the upper aerodigestive tract (UADT) were studied. Of these, 15 (11%) had laryngeal (supraglottic) involvement. In all of these patients, the disease was above the true vocal folds. Seventy-four (52%) patients had involvement of 1 anatomic zone (most common was the oral cavity), and 67 (48%) had involvement of multiple zones. With regard to each zone, 105 (75%) patients had involvement of the oral cavity, 50 (36%) the oropharynx, 8 (6%) the hypopharynx, 42 (30%) the parapharynx, and 12 (9%) had retropharygeal disease (some patients had multiple zones involved). No patients were identified with glottic, subglottic, or tracheal involvement. Based on our large series, airway involvement in head and neck lymphatic malformations may occur at multiple sites above the glottis. A high percentage of these patients have involvement of the oral cavity (75%) and oropharynx (35%). None involve the glottis, subglottis, or trachea.

Laryngeal involvement in rheumatoid arthritis

AbstractThe prevalence of laryngeal involvement in Rheumatoid Arthritis (RA) ranges from 13 to 75%. The specific RA manifestations include the cricoarytenoid arthritis and the presence of rheumatoid nodules in the vocal folds. ObjectiveThe objective of this study is to evaluate the prevalence of dysphonia and laryngeal alterations on videolaryngoscopy in RA patients and their association with disease activity. MethodThis is a clinical cross-sectional study that evaluated patients with rheumatoid arthritis as to their disease activity score in 28 joints (DAS-28), laryngeal symptoms, application of a Portuguese version of the Voice Handicap Index and videolaryngoscopy findings, comparing them with a control group. ResultsWe evaluated 47 (54%) patients with rheumatoid arthritis and 40 (46%) controls. The prevalence of dysphonia and videolaryngoscopy changes was respectively 12.8% and 72.4% in patients with RA. The mean of DAS-28 was 3.3 ± 1.2; 26 (74.3%) of 35 patients presenting active disease had laryngeal changes (p = 0.713). Posterior laryngitis was the most common diagnosis (44.7%). ConclusionThe prevalence of laryngeal disorders in RA patients was 72.4% and the prevalence of dysphonia was 12.8%. There was no significant relationship between laryngeal disorders and disease activity.

Acute angioedema

Angioedema is characterized by localized swelling of subcutaneous tissues or mucosa of the upper respiratory or gastrointestinal tract. Laryngeal involvement may threaten airway patency and can be fatal if not addressed promptly. There are several distinct subtypes of angioedema, caused by different pathological processes involving a range of proinflammatory mediators. In the emergency department, it is essential not only that acute angioedema is identified as quickly as possible but also that the likely working diagnosis is established so that the most effective treatment may be administered to resolve potentially life-threatening swelling. In this paper, we present an overview of the various types of angioedema, and offer a practical diagnostic and therapeutic approach to their management.

English

Rhinoscleroma is a chronic, progressive, granulomatous disease caused by Klebsiella Rhinoscleromatis. It generally involves the nose but can affect other parts of the respiratory tract. It is uncommon but still evident in some parts of the world. We are reporting a case of a 25 year-old male who presented with nasal mass, dyspnoea and hoarseness of voice and created a diagnostic dilemma due to laryngeal involvement but histopathological examination revealed the diagnosis of rhinoscleroma. Apart from surgical debridement of the mass in nasal cavity, the patient was also treated with streptomycin, rifampicin and ciprofloxacin. He was asymptomatic in the follow-up. It is thus important to consider rhinoscleroma in cases of chronic nasal obstruction and histopathology plays a vital role in confirming the diagnosis.

Herpes simplex laryngitis following primary genital herpes

Primary genital herpes is associated with involvement of extragenital sites like thighs, buttocks, fingers and pharynx. This involvement occurs due to autoinoculation, orogenital exposure from the source and also seeding due to viremia in the initial period. Involvement of larynx in a case of primary genital herpes is extremely rare prompting us to report this case.

Urbach-Wiethe Disease: A Rare Cause of Hoarseness of Voice

ABSTRACTUrbach-Wiethe disease is a rare, autosomal recessive disorder, characterized by infiltration of periodic acid-Schiff positive hyaline material into the skin, oral cavity, larynx and internal organs. The clinical manifestations include hoarseness of voice, beaded papules along the eyelid margins, skin scarring and an inability to protrude the enlarged and thickened tongue. Laryngeal involvement is typical and causes hoarseness of voice. In this paper, we present a case of a middle-aged female with clinical features suggestive of Urbach-Wiethe disease. This entity is of interest to the otolaryngologist as it is a rare cause of hoarseness of voice.How to cite this articleKoganti D. Urbach-Wiethe Disease: A Rare Cause of Hoarseness of Voice. Int J Phonosurg Laryngol 2013;3(2):61-64.

Disseminated non-Hodgkin's lymphoma presenting as bilateral salivary gland enlargement: a case report

Non-Hodgkin's lymphoma (NHL) constitutes a group of malignancies those arises from cellular components of lymphoid or extranodal tissues. The head and neck is the most common area for the presentation of these lymphoproliferative disorders. Primary involvement of salivary glands is uncommon. This report described a case of a 73-year-old female patient who presented with involvement of both nodal and extranodal sites, with predominant involvement of salivary glands. The tumor staging worked up along with imaging, histopathological, and immunohistochemical findings were discussed. Computed tomographic images showed the involvement of Waldeyer's ring, larynx, orbit, and spleen. This report described imaging and prognostic tumor markers in diagnosing, treatment planning, and prognosis.

Descending necrotizing mediastinitis: Report of three cases and review of literature

Descending necrotizing mediastinitis (DNM) is a rare, severe, life-threatening suppurative infection of the fascial covering of mediastinal cavity. Oropharyngeal cavity is connected to the mediastinum with various fascial planes. The retropharyngeal space is called the dangerous space as through this fascial space infection from the mouth and neck rapidly spread to the mediastinum. Gravity and the negative intrathoracic pressure facilitate the spread of infection into the thoracic cavity. Common clinical presentations are fever, odynophagia, dysphonia, dry cough, neck swelling and chest pain. Computerized tomography of neck and chest will diagnose DNM early and it helps in the grading of the disease. Broad spectrum antibiotic therapy and fluid resuscitation with surgical drainage is essential therapeutic aspect. Combination of transcervical and transthoracic drainage is reported to have significantly more survival benefit than the trans-cervical drainage alone. Percutaneous and video-assisted mediastinoscopic drainage has obvious advantages compared with open surgical drainage. We report three cases of DNM, with recurrent laryngeal nerve involvement successfully treated by video-assisted thoracoscopy and percutaneous drainage.

Undiagnosed light chain systemic amyloidosis: does it matter to anesthesiologists? -a case report-

Light chain systemic amyloidosis is rare but may accompany laryngeal or pulmonary involvement, which may increase the risk in airway management. We present a case of a patient planned for resection of cervical epidural mass. The patient had face and neck ecchymoses and purpuras with an unknown cause. Mask ventilation and intubation were successful, but the operation was cancelled to evaluate bleeding from facial skin lesions. A diagnosis of light chain systemic amyloidosis prompted evaluation of involvement of other organs and treatment. This case shows the importance of preoperative evaluation and careful airway management in patients with systemic amyloidosis.

Pulmonary Manifestations of Inflammatory Bowel Disease

1Department of Medicine, McMaster University, Hamilton, Ontario; 2Department of Medicine, University of Calgary, Calgary, Alberta Correspondence: Dr David Ryan Stather, Division of Respiratory Medicine, Health Sciences Center, 3330 Hospital Drive Northwest, Calgary, Alberta T2N 4N1. Telephone 403-210-3866, fax 403-944-1577, e-mail davestather@yahoo.ca Three patients with Crohn disease were evaluated for cough and dyspnea. A 63-year-old woman was found to have bronchiolitis obliterans and bronchiectasis that responded to oral prednisone (Figure 1A). A 38-year-old man was found to have airflow obstruction and pulmonary nodules. Open lung biopsy revealed necrobiotic nodules and bronchiolitis obliterans (Figure 1B). A 49-year-old man experienced severe airflow obstruction and was confirmed via bronchoscopy and imaging to have three different manifestations of inflammatory bowel disease (IBD); tracheobronchitis, bronchiectasis and bronchiolitis obliterans (Figures 1C and 1D). Improvements in airflow obstruction and symptoms occurred with oral prednisone. Although pulmonary manifestations have historically been believed to be a rare complication of IBD, recent publications suggest that this may be more frequent than previously recognized (1,2). Respiratory manifestations of IBD are varied and include bronchiectasis (most common), tracheobronchitis (including rare laryngeal and glottic involvement), chronic bronchitis, bronchiolitis obliterans, pulmonary nodules (necrobiotic or granulomatous), pleuritis and a variety of parenchymal and interstitial diseases (1). IBD patients are at increased risk for venous thromboembolic disease and a growing body of literature suggests a link between IBD and sarcoidosis, asthma and alpha-1 antitrypsin deficiency (1). Pulmonary manifestations rarely precede the diagnosis of IBD, do not correlate with colonic disease and may present years after colonic disease is controlled (3). A high index of suspicion for respiratory disorders is warranted in patients with IBD because it may be easily identified with appropriate history, pulmonary function testing and imaging, and may be treatable if identified early.

Laryngeal Manifestations of Rheumatoid Arthritis

Rheumatoid arthritis is a destructive autoimmune disease that affects 3% of the adult population. It is characterized by the formation of both articular and extra-articular lesions with predilection for small joints. There are ubiquitous reports on the head and neck manifestations of RA with emphasis on the larynx. The laryngeal presenting features of this systemic disease may mimic a plethora of medical conditions, inflammatory and neoplastic. The main phonatory and respiratory symptoms are often subtle and misleading. This paper represents a literature review of the laryngeal manifestations of RA with emphasis on the clinical symptoms, laryngeal findings, diagnosis, and treatment. An early diagnosis of laryngeal involvement may prevent drastic complications.

Traditional transcutaneous approaches in head and neck surgery.

The treatment of laryngeal and hypopharyngeal malignancies remains a challenging task for the head and neck surgeon as the chosen treatment modality often has to bridge the gap between oncologically sound radicality and preservation of function. Due to the increase in transoral laser surgery in early tumor stages and chemoradiation in advanced stages, the usage of traditional transcutaneous approaches has decreased over the recent past. In addition, the need for a function-sparing surgical approach as well as highest possible quality of life has become evident. In view of these facts, rationale and importance of traditional transcutaneous approaches to the treatment of laryngeal and hypopharyngeal malignancies are discussed in a contemporary background. The transcutaneous open partial laryngectomies remain a valuable tool in the surgeon's armamentarium for the treatment of early and advanced laryngeal carcinomas, especially in cases of impossible laryngeal overview using the rigid laryngoscope. Open partial laryngetomies offer superior overview and oncologic safety at the anterior commissure, especially in recurrencies. In select advanced cases and salvage settings, the supracricoid laryngectomy offers a valuable tool for function-preserving but oncologically safe surgical therapy at the cost of high postoperative morbidity and a very demanding rehabilitation of swallowing.In hypopharyngeal malignancies, the increasing use of transoral laser surgery has led to a decline in transcutaneous resections via partial pharyngectomy with partial laryngectomy in early tumor stages. In advanced stages of tumors of the piriform sinus and the postcricoid area with involvement of the larynx, total laryngectomy with partial pharyngectomy is an oncologically safe approach. The radical surgical approach using circumferent laryngopharyngectomy with/without esophagectomy is indicated in salvage cases with advanced recurrences or as a primary surgical approach in patients where chemoradiation does not offer sufficient oncologic control or preservation of function. In cases with impending reconstruction, fasciocutaneous free flaps (anterolateral thigh flap, radial forearm flap) seem to offer superior results to enteric flaps in cases where the cervical esophagus is not involved leading to better voice rehabilitation with fewer complications and postoperative morbidity. In salvage situations, the Gastroomental Free Flap has proven to be a valuable tool.In conclusion, the choice of a surgical treatment modality is influenced by the patient's anatomy, tumor size and location as well as the surgeon's personal expertise.

Reconstruction of Pharyngeal Defects with a Submental Island Flap after Hypopharyngeal Carcinoma Ablation

Purpose: This study aimed to evaluate the oncologic and functional results of pharyngeal defect reconstruction using a submental island flap in hypopharyngeal cancer patients. Methods: Functional and oncologic results were assessed in 14 patients based on a retrospective chart review. Speech function grading was as follows: 1 = excellent (>70% intelligibility); 2 = good (40–70% intelligibility), and 3 = poor (<40% intelligibility). Swallowing function score was stratified as 1 = full diet (excellent), 2 = soft diet (excellent-good), 3 = liquid diet (good), 4 = combined oral and gastric tube (good-poor), and 5 = gastric tube-dependent (poor). Results: All flaps survived well. Salivary fistula with infection was found in 1 patient and treated conservatively. The mean length of hospitalization, and speech and swallowing scores according to laryngeal invasion in 11 patients after partial pharyngectomy were 21.63 ± 4.31 versus 11 ± 2.00 (p = 0.003), 2.38 ± 0.5 versus 1.67 ± 1.16 (p = 0.18) and 3.88 ± 0.84 versus 3.33 ± 1.53 (p = 0.46), respectively. Speech and swallowing returned to good-excellent in 63.6% and good in 45.5% of patients after surgery. Conclusions: The submental island flap is reliable for reconstructing laryngopharyngeal defects after ablation of hypopharyngeal cancer. Speech and swallowing are restored to good function in half of the patients. Laryngeal involvement of the cancer is predictive of longer hospitalization.

Laryngeal electromyography in dysphonic patients with incomplete glottic closure

The lack of specificity in laryngoscopical examination requires that the diagnosis of superior laryngeal and recurrent laryngeal nerve involvement be carried out with the aid of electromyography. ObjectiveThis study aims to assess the electrophysiological function of the superior and inferior laryngeal nerves by measuring the electrical activity of the muscles they innervate in dysphonic patients with incomplete closure of the vocal folds during phonation. MethodThirty-nine patients with incomplete glottic closure were enrolled in a prospective study and had their cricothyroid, thyroarytenoid, and lateral cricoarytenoid muscles examined bilaterally through electromyography. Insertion activity, electrical activity at rest (fibrillation, positive wave and fasciculation) and during muscle voluntary contraction (recruitment, amplitude, potential length and latency between electrical activity and phonation) were measured. ResultsNo altered test results were observed for parameters insertion activity and electrical activity at rest. None of the patients had recruitment dysfunction. The mean electrical potential amplitude values were within normal range for the tested muscles, as were potential durations and latency times between the onset of electrical activity and phonation. ConclusionNo signs of denervation were seen in the thyroarytenoid, cricothyroid, and lateral cricoarytenoid muscles of the studied patients.

Simultaneous involvement of lungs, larynx and middle ear by tuberculosis -a rare case

Simultaneous involvement of lungs, larynx and middle ear by tuberculosis is very rare. We present a rare case of simultaneous involvement of larynx and ear in a patient with pulmonary tuberculosis. A 17 years old male presented with fever and cough for 8 months, bilateral deafness for 5 months and hoarseness of voice for 3 months. The patient gave history of anorexia and progressive weight loss and history of close contact with tuberculosis patient. There were coarse crepitations on auscultation of both lungs. Indirect laryngoscopy revealed diffuse nodular swelling as well as thickening of the vocal cords. Examination of both ears revealed pale-yellow granulation tissue. ESR was 94 mm in 1st hour and chest radiograph showed diffuse patchy opacities extending over both lung fields. The results of two sputum examinations showed numerous acid-fast bacilli Histopathologic examination of punch biopsy from right and left ear lesions and biopsy tissue from laryngeal lesion taken by endoscopic instrument revealed granulomatous inflammation histologically consistent with tuberculosis.The patient responded well and promptly to the antituberculous therapy. The aim of this article is to create an awareness of Ear Nose Throat tuberculosis and to consider tuberculosis in the differential diagnosis of ear and laryngeal diseases and to emphasize the need for prompt recognition and treatment. DOI: http://dx.doi.org/10.3329/jdnmch.v17i1.12195 J. Dhaka National Med. Coll. Hos. 2011; 17 (01): 53-55

Dysphonia and dermatomyositis: An unusual manifestation

We report a case of a 39-year-old female with a recent diagnosis of dermatomyositis and dysphonia. Dermatomyositis is a connective tissue disease with multisystem involvement: cardiac, pulmonary, musculoskeletal, gastrointestinal, and dermatologic are the most common. While dermatomyositis affects thousands of individuals in the United States, laryngeal involvement has only been described in a single case report to date.

Rosai-Dorfman Disease with Isolated Laryngeal Involvement

Rosai-Dorfman disease is a rare histiocyte disorder that is typically characterized by massive cervical lymphadenopathy. Isolated extranodal involvement is uncommon, and isolated laryngeal involvement is extremely rare. We report an unusual case of Rosai-Dorfman disease with isolated laryngeal involvement that led to recurrent dysphonia and airway obstruction. We discuss the challenges we faced in reaching a correct pathologic diagnosis and in deciding on an appropriate treatment regimen. Based on our experience, we believe that Rosai-Dorfman disease should be considered as a differential diagnosis in patients who present with a recurrent inflammatory (histiocytic) mass lesion of the larynx.

Laryngeal involvement in pemphigus vulgaris: a proposed classification

(1) To investigate the incidence of laryngeal involvement in a large series of patients with pemphigus vulgaris, using endoscopic examination, (2) to describe the lesions, and (3) to establish a classification of laryngeal involvement in pemphigus vulgaris based on the location of the lesions. Prospective study. A total of 40 sequentially treated pemphigus vulgaris patients, diagnosed using clinical, histological and immunofluorescence criteria, were evaluated for laryngeal manifestations using endoscopic examination. The results were used to establish a graded classification of laryngeal involvement according to the location of the lesions. Active laryngeal lesions (ulcers or blisters) were found in 16 patients (40 per cent). Of these, 37.5 per cent were classified as grade I, 20 per cent as grade II, 20 per cent as grade III and 17.5 per cent as grade IV. Laryngeal involvement is common in pemphigus vulgaris and must be considered at the point of diagnosis. Grade I lesions are the most frequent.

Behcet’s disease impairs voice quality without laryngeal and hypopharyngeal involvement

The objective of the study was to investigate voice evaluation parameters in Behcet's disease patients. A prospective controlled study was performed in a tertiary referral center. A total of 31 patients (21 female, 10 male) with a diagnosis of Behcet's disease had voice evaluations by means of laryngostroboscopy, acoustic analysis, aerodynamic measurements and perceptual assessment. Data obtained from the patients were compared to 31 healthy control subjects. Laryngeal endoscopy was within normal limits in all patients. The mean fundamental frequency in male control subjects (134 ± 14 Hz) was significantly higher than in male patients (124 ± 20 Hz), (p = 0.043). Mean intensity was significantly higher in control subjects (74 ± 5 dB) than in the patients (63 ± 4.6 dB), (p < 0.001). Shimmer in patients (3.4 ± 2.5) was significantly higher than in control subjects (2 ± 1.3), (p = 0.01). Maximum phonation time in control subjects (25 ± 5.8 s) was significantly longer than in patients (20 ± 7.9 s), (p = 0.007), and s/z ratio was found to be nearly equal between patients (0.9 ± 0.2) and control subjects (0.96 ± 0.1), (p > 0.05). The patients showed a mean GRBAS score of 1.8 ± 1.9 and the control group showed a mean score of 0.48 ± 1.06, (p = 0.002). The VHI-10 scale revealed a mean score of 2.2 ± 4.8 in BD patients and 2 ± 2 in control subjects (p > 0.05). Behcet's disease impaired voice quality without laryngostroboscopically visible laryngeal and hypopharyngeal involvement. This impairment was documented by objective voice evaluation methods including acoustic analysis and aerodynamic voice measurements and by subjective voice evaluation method including perceptual assessment.

Renin–angiotensin system inhibitors and angioedema

Angioedema is a serious complication of renin-angiotensin system inhibitor therapy. The incidence is 0.1-0.7%. It consists of nonpitting edema and involves the face and lips. In severe cases, it extends to pharyngeal and laryngeal structures. Decreased degradation of bradykinin and its metabolites is thought to be a culprit. When the angiotensin-converting enzyme is inhibited, bradykinin metabolism is dependent on degradation by neutral endopeptidase, dipeptidyl peptidase IV, and aminopeptidase P. When these enzymes are inhibited, as in treatment of diabetes or in transplant recipients, the incidence of angioedema increases significantly. African-Americans, people over 65, women, and those with a history of smoking are especially at risk. A fiberoptic laryngeal examination should be performed in all patients. Patients with rapid progression of symptoms are at risk for airway compromise. Supportive treatment with steroids and antihistamines is not very effective. Recently, icatibant, a bradykinin receptor antagonist, has been used to successfully shorten the resolution of edema. Trauma of the airway, especially during difficult intubation, may precipitate severe angioedema. In cases with laryngeal involvement, fiberoptic intubation may be necessary. After the episode of angioedema, lifetime discontinuation of all renin-angiotensin inhibitors may be warranted.