Pharyngoepiglottic Fold Research Articles

A Case of Primary Cryptococcosis of the Pharyngo-epiglottic Fold in an Immunocompetent Patient

Cryptococcus is a pathogenic fungus that can cause various infections mainly in an immunocompromised host. Cryptococcal yeasts are easily inhaled, so pulmonary infection is the most commonly encountered, but in immunocompetent status, primary cryptococcosis occurs rarely in the pharyngo-epiglottic fold. A 75-year-old male came to our clinic with the complaint of foreign body sensation in the throat that lasted for three months. Rigid laryngoscopy showed a circular mass in the pharyngo-epiglottic fold and we performed laryngeal microsurgery with CO2 laser to remove it. The patient was pathologically diagnosed as cryptococcosis. We report this case of rare, atypical cryptococcosis in the pharyngo-epiglottic fold along with a related literature review.

Development and reliability of the revised Patterson Edema Scale.

The Patterson Edema scale was developed in 2007 to address the lack of a reliable, sensitive scale to measure laryngeal and pharyngeal oedema in patients with head and neck cancer. The objective of this study was to revise the existing Patterson scale to improve its reliability and utility. Prospective investigation. Academic medical center. Speech-Language Pathologists, Otolaryngologists, and Radiation Oncologists. Ratings using the Revised Patterson Edema Scale. A consensus group reviewed existing literature regarding the performance of the original Patterson scale and revised the existing scale in regard to items to be included and descriptors for each severity level. The scale was then utilised by 18 speech language pathologists from the US and UK with>2years-experience working with dysphagia and dysphonia with endoscopy. Each SLP rated a total of eight parameters (epiglottis, vallecula, pharyngoepiglottic folds, aryepiglottic folds, arytenoids, false vocal folds, true vocal folds and pyriform sinuses) using the Revised Patterson Edema Scale. Feedback was solicited from raters regarding areas where clarity was lacking for further scale revision. Scale revisions were completed and additional ratings were completed by otolaryngologists, radiation oncologists and less experienced SLP providers to establish reliability across disciplines. Quadratic weighted Kappa values were obtained to establish interrater reliability. Feedback received from raters included suggestions for clarification of how to rate unilateral oedema, use of a standard task battery to visualise and rate structures consistently, and clarification of true vocal fold oedema rating parameters. Overall interrater reliability was established using quadratic weighted Kappa with good agreement noted for the epiglottis, vallecula, arytenoids andfalse vocal folds; moderate agreement noted for aryepiglottic folds, pharyngoepiglottic folds and pyriform sinuses; and fair agreement noted for true vocal folds. The Revised Patterson Edema Scale demonstrates moderate-substantial interrater reliability for most parameters across multiple disciplines and experience levels, with the exception of the true vocal folds where agreement was fair. We believe the Revised Patterson Oedema Scale provides a reliable tool for clinicians and researchers to rate oedema in the supraglottic larynx and pharynx following treatment for head and neck cancer.

Grill-Cleaning Wire Brush Bristle Ingestion: Case Series and Review of the Literature

The authors report a small case series of an unusual ingested foreign body, wire brush bristles, whose small size can present a challenge for endoscopic removal. The authors describe transnasal endoscopic removal and provide a literature review. From 2011 to 2017, 8 patients presented to an academic tertiary medical center with ingestion of wire brush bristles. The patients' medical records were reviewed and are described in this report, along with a literature review. In 4 patients, the bristles were in the lingual tonsils. In 1 patient, a bristle was within the pharyngoepiglottic fold and lingual tonsils. Three patients underwent office removal with a fiber-optic laryngoscope under local anesthesia. Two patients underwent direct laryngoscopy with bristle removal. In 1 patient the wire bristle transected the esophagus, requiring an open procedure. One patient presented with a complicated deep-space neck infection. Wire brush bristles easily become displaced and subsequently become lodged in the upper aerodigestive tract. Localization of a bristle can be difficult on examination and laryngoscopy. Radiography can be performed, but computed tomographic examination with contrast is superior for precise localization for preparation for an operative approach. Depending on the precise location of the bristle, endoscopic removal using a fiber-optic channeled scope may be a safe and effective solution. Case Series, IV.

Transoral Oropharyngeal Resection Classification: Proposal of the SCORL Working Group

Introduction and goalsThere has been a very significant increase in the use of minimally invasive surgery has in the last decade. In order to provide a common language after transoral surgery of the oropharynx, a system for classifying resections has been created in this area, regardless of the instrumentation used. MethodsFrom the Oncology Working Group of the Catalan Society of Otorhinolaryngology, a proposal for classification based on a topographical division of the different areas of the oropharynx is presented, as also based on the invasion of the related structures according to the anatomical routes of extension of these tumours. ResultsThe classification starts using the letter D or I according to laterality either right (D) or left (I). The number of the resected area is then placed. This numbering defines the zones beginning at the cranial level where area I would be the soft palate, lateral area II in the tonsillar area, area III in the tongue base, area IV in the glossoepiglottic folds, epiglottis and pharyngoepiglottic folds, area V posterior oropharyngeal wall and VI the retromolar trigone.The suffix p is added if the resection deeply affects the submucosal plane of the compromised area. The different proposed areas would, in theory, have different functional implications. ConclusionProposal for a system of classification by area to define different types of transoral surgery of the oropharynx, and enable as sharing of results and helps in teaching this type of technique.

Clasificación de las resecciones transorales en la orofaringe: propuesta del grupo de trabajo de la Sociedad Catalana de Otorrinolaringología

Introduction and goalsThere has been a very significant increase in the use of minimally invasive surgery has in the last decade. In order to provide a common language after transoral surgery of the oropharynx, a system for classifying resections has been created in this area, regardless of the instrumentation used. MethodsFrom the Oncology Working Group of the Catalan Society of Otorhinolaryngology, a proposal for classification based on a topographical division of the different areas of the oropharynx is presented, as also based on the invasion of the related structures according to the anatomical routes of extension of these tumours. ResultsThe classification starts using the letter D or I according to laterality either right (D) or left (I). The number of the resected area is then placed. This numbering defines the zones beginning at the cranial level where area I would be the soft palate, lateral area II in the tonsillar area, area III in the tongue base, area IV in the glossoepiglottic folds, epiglottis and pharyngoepiglottic folds, area V posterior oropharyngeal wall and VI the retromolar trigone.The suffix p is added if the resection deeply affects the submucosal plane of the compromised area. The different proposed areas would, in theory, have different functional implications. ConclusionsProposal for a system of classification by area to definedifferent types of transoral surgery of the oropharynx, and enable as sharing of results and helps in teaching this type of technique.

Retropharyngeal liposarcoma: A rare cause of dysphagia

IntroductionLiposarcoma is a rare malignant mesenchymal tumour. Very few cases of retropharyngeal liposarcoma have been reported in the literature. SummaryA 30-year-old woman with no notable history reported swallowing disorders for the past year associated with dysphonia. Nasal endoscopic examination demonstrated a tumour arising from the left lateral pharyngeal wall, ascending as far as the junction of the free margin of the epiglottis, aryepiglottic fold, and pharyngoepiglottic fold and obliterating the ipsilateral pyriform sinus with preservation of cord mobility. The rest of the physical examination was normal. The preoperative assessment was completed by gadolinium-enhanced MRI of the neck. Open surgery was performed. Definitive histological examination concluded on dedifferentiated liposarcoma with negative resection margins. Following staging chest computed tomography that did not reveal any metastases, the multidisciplinary consultation meeting decided to deliver adjuvant volumetric modulated arc therapy. No recurrence was observed nine months post-treatment. DiscussionRetropharyngeal liposarcoma is a rare tumour. The authors report the first case of a dedifferentiated histological subtype in this site. A review of the literature completes this case report by providing a description of prognostic factors and the various treatments.

Untreated Cleft Palate a Unique Surgical Contraindication in Carcinoma of the Pyriform Fossa

ABSTRACT Background/objectives Swallowing problems following total laryngectomy are significantly lesser compared to other partial laryngectomies as a permanent seperation between the trachea and esophagus is seen in the earlier. Sometimes, the patient complains of difficulty in propelling bolus through the oral cavity and pharynx as a result of the loss of hyoid bone, which is the anchor for the tongue. The increased pressure in the narrowed pharyngoesophageal segment following laryngectomy requires the tongue to move with greater force. Setting Department of Head and Neck Oncosurgery, Kidwai Memorial Institute of Oncology, Bengaluru. Case report A 52-year-old man with history of difficulty and pain while swallowing and diagnosed as squamous cell carcinoma of the right pyriform fossa extending to the pharyngoepiglottic fold. Incidently, the patient had an old untreated cleft palate. Assessment of the pharyngeal wall involvement on direct laryngoscopy proved that pectoralis major myocutaneous flap patch was needed to reconstruct the pharyngeal lumen. Cleft palate proved a contraindication for surgery as the oral swallowing phase would be affected. Conclusion Current management protocols of hypopharyngeal cancers include multifactorial assessment of anatomical and functional outcomes and rehabilitation. Even though no literature is found stating cleft palate as the contraindication for total laryngectomy, chemoradiation was preferred citing swallowing problems. How to cite this article Naik SM. Untreated Cleft Palate a Unique Surgical Contraindication in Carcinoma of the Pyriform Fossa. Int J Phonosurg Laryngol 2012;2(1):33-36.

European laryngological society propose four types endoscopic supraglottic laryngectomy

The limited excision addresses small superficial lesions affecting free edge of the epiglottis, the aryepiglottic fold or the superior edge of the arytenoid. The median supraglottic laryngectomy excluding the pre-epiglottic space addresses small superficial T1 lesions of the endolaryngeal epiglottis. The incision line extends to the pre-epiglottic space but does not aim at removing the pre-epiglottic space entirely. The pharyngo-epiglottic folds, aryepiglottic folds, and ventricular folds are preserved. The median supraglottic laryngectomy including the pre-epiglottic space addresses T1 and T2 lesions of the endolaryngeal epiglottis. The entire pre-epiglottic space is removed as far as possible. Depending on extent of the lesion, the resection can include one or two ventricular bands and the aryepiglottic folds. The lateral supraglottic laryngectomy addresses lesions affecting the three folds or T1 and T2 lesions of the aryepiglottic fold. The procedure removes free edge of the epiglottis ipsilateral to the lesion, the area of the three folds and the aryepiglottic fold. The resection can include the inner wall and anterior angle of the pyriform sinus, the entire ventricular fold and the arytenoid (provided it is mobile).

Supraglottic hemipharyngolaryngectomy for the treatment of T1 and T2 carcinomas of laryngeal margin and piriform sinus

We evaluated the functional and oncologic results of supraglottic hemipharyngolaryngectomy as treatment for T1 and T2 lateral laryngeal margin and piriform sinus carcinomas. Eighty-seven patients underwent this surgical treatment. The disease was classified T1 in 14 of these cases (16.1%) and T2 in 73 cases (83.9%). The nodal status indicated 39 cases of N0 (44.8%), 18 cases of N1 (20.7%), 28 cases of N2 (32.2%), and two cases of N3 (2.2%). With regard to the N0 cases, 15 (38.4%) were positive at the histologic examination. Within the N+ group, 52.1% involved capsular rupture. Two patients died of complications during the postoperative period. The mean duration of nasogastric tube feeding was 20 days. Six patients (7.27%) had feeding resumption problems. All patients were decanulated after a mean period of 16 days. All patients underwent postoperative radiation therapy, except two with T1N0N- disease and three who had previously undergone this treatment. The 5-year actuarial survival rate was 60.3% (T1, 83.3%; T2, 49.9%). The rates of local and regional recurrence, second primary cancer, and metastasis were 19.5%, 24.1%, and 28.1%, respectively. The infringement of the pharyngoepiglottic fold was significantly correlated with locoregional recurrence. The survival rate was significantly correlated with the nodal status and extracapsular spread. Initial staged cancers of the laryngeal margin and piriform sinus can be successfully managed with conservative surgery called supraglottic hemipharyngolaryngectomy combined with nodal neck dissection. Postoperative radiation therapy is still recommended in most cases because of the high recurrence potential and prevalence of secondary regional cancers. This combined treatment seems to be a suitable therapeutic choice in the treatment of patients with T1 and T2 carcinomas of the laryngeal margins and piriform sinus.

Long-term outcomes after external beam irradiation and brachytherapy boost for base-of-tongue cancers

Purpose To assess long-term efficacy and toxicity associated with external beam irradiation (EBRT) and interstitial 192Ir implantation for the treatment of squamous carcinoma of the base of tongue. Methods and materials Between April 1975 and December 1993, 41 patients with base-of-tongue carcinomas were treated with 192Ir interstitial implants after EBRT at Stanford University. One patient had Stage I, 6 had Stage II, 7 had Stage III, and 27 had Stage IV tumors. Twenty-eight patients had cervical lymph node involvement at diagnosis. All received EBRT to a median dose of 50 Gy (range 48.9–68 Gy) to the primary tumor and regional lymph nodes before brachytherapy. Interstitial implant was performed 2–4 weeks after EBRT. Intraoperatively, nylon catheters were placed via steel trocars into the base of tongue, glossotonsillar groove, and pharyngo-epiglottic fold using a catheter looping technique. Twenty-three of 28 node-positive patients also underwent simultaneous neck dissections. Postoperatively, the 192Ir seeds were inserted and allowed to remain in place for approximately 35 h to achieve a median tumor dose of 26 Gy (range 20–34 Gy) to a median volume of 73 cc. Survival, local control, and complications were assessed. Results With a median follow-up of 62 months (range 9–215) for all patients and 90 months for alive patients, the 5-year Kaplan-Meier survival estimate was 66%. The 5-year local control rate was 82%, with 7 patients recurring locally, 2 of whom were salvaged with surgery. Nodal control was achieved in 93% of patients with either EBRT alone or in combination with neck dissection. The 5-year freedom from distant metastasis rate was 83%. Acute complications included transient bleeding (5%) and infection (8%). Late complication included soft-tissue necrosis/ulceration (7%), osteoradionecrosis (5%), and xerostomia. Conclusion Base-of-tongue carcinoma can be effectively treated with EBRT and 192Ir implant boost. Local control is excellent and complication rates are acceptable.

Indication and surgical technique for extended hemilaryngectomy.

Previous experience has shown that conservation of the healthy hemilarynx is possible for the treatment of extended lateralized laryngeal and hypopharyngeal cancers. One major indication for supracricoid hemilaryngectomy is glottic cancer involving either the arytenoid or Morgagni's ventricle. Hemilaryngopharyngectomy is also indicated when tumor of the pyriform sinus involves its anterior part, lateral wall, medial wall and ary- and pharyngoepiglottic folds. Supracricoid hemilaryngopharyngectomy was performed in seven cases. The resection consisted of removal of the surpacricoid hemilarynx and ipsilateral pyriform sinus. The reconstruction was performed by elevating the posterior pharyngeal wall and suturing the mucosa to the midline. This surgical technique provided good functional results. Patients had no airway impairments, but the recovery of satisfactory deglutition may require 14-32 days. Phonatory rehabilitation was successful, and each patient had a satisfactory vocal quality. Postoperative irradiation did not affect the functional results.

Hyoepiglottic ligament in supraglottic cancer.

The hyoepiglottic ligament (HL) is a connective tissue structure that serves as the roof of both the paraglottic and the preepiglottic spaces and thereby anatomically separates the supraglottic larynx from the tongue base. Whole mount serially sectioned larynges with supraglottic cancer were reviewed to help clarify cephalad spread of cancer in this region. The whole mount slides were analyzed from 70 laryngectomy specimens that were resected for supraglottic cancer. The HL was breached by cancer in 13 specimens, and all of these displayed clinical and histopathologic invasion of the preepiglottic and paraglottic spaces. Invasion of the suprahyoid epiglottis was noted in 9 specimens, and invasion of the aryepiglottic fold in 4. There were no instances in which cancer escaped from the deep compartments of the supraglottic larynx to the tongue base without synchronous erosion of the suprahyoid epiglottis (insertion of the medial HL) or the pharyngoepiglottic fold (lateral HL). The HL is a resilient connective tissue barrier to the spread of cancer from the supraglottis to the tongue base. This investigation reinforced the concept that, typically, the HL acts as a deep cephalad surgical boundary in resecting supraglottic cancer that 1) is confined to the laryngeal membranes and 2) does not clinically invade the suprahyoid epiglottis.

192Ir pharyngoepiglottic fold interstitial implants. The key to successful treatment of base tongue carcinoma by radiation therapy.

Twenty-eight patients with squamous carcinomas of the base tongue were seen and evaluated in a conjoint Head and Neck Tumor Board at Stanford between 1976 and 1982. Fourteen patients were treated by combined external beam and interstitial irradiation, 11 of whom had Stage III and IV carcinomas (American Joint Committee). An initial dose of 5000 to 5500 rad was first delivered by external beam irradiation in 5 to 5.5 weeks, followed approximately 3 weeks later by an iridium 192 (192Ir) interstitial implant boost by the trocar and loop technique. The key to successful treatment of these neoplasms was found to be the use of a lateral percutaneous cervical technique, which placed horizontal loops through the oropharyngeal wall above and below the hyoid bone; the superior loop included the pharyngoepiglottic fold and the tonsilloglossal groove. Standard multiple loop implants (submentally inserted) of the base tongue from the vallecula anteriorly to the circumvallate papillae were also used routinely. This approach has been successful, since 10 of the 14 patients (71%) remain without evidence of disease (mean follow-up, 32 months). There have been only two local recurrences, both on the pharyngoepiglottic fold in patients who did not receive the now standard pharyngoepiglottic fold/lateral pharyngeal wall implants. No patients have relapsed after 18 months. The other 14 patients were treated prospectively during the same period by combining initial resection, radical neck dissection, and postoperative irradiation. In this group, there were more locoregional failures compared to the group treated with radiation therapy alone (5 tongue recurrences and 7 neck relapses); in addition, more severe complications were noted in these 14 patients who received surgery and postoperative irradiation. The authors believe that combined external beam and interstitial irradiation is effective treatment for base tongue carcinomas, especially when the high-dose distribution includes the adjacent tonsilloglossal groove, pharyngoepiglottic fold, and oropharyngeal wall to and below the level of the hyoid bone, in addition to treating an adequate base tongue volume.

Radiation treatment of lateral epilaryngeal cancer. Prognostic factors and results.

Treatment results of epilaryngeal cancer are rarely individualized in the world literature. For this purpose, we have reviewed the records of 167 patients with squamous cell carcinoma of the lateral epilarynx who received radical radiotherapy at the Institut Curie on a megavoltage unit, between 1959-1975. Two-thirds of the lesions were located at the junction of the ary- and pharyngo-epiglottic folds and lateral border of the epiglottis. Forty-four percent of patients had advanced primary lesions (T3, T4) and over 50% had palpable neck nodes at the time of presentation. The absolute survival for the entire patient population at 3 and 5 years was 44% and 32%. Local control for T1 and T2 tumors at 3 years was about 80%. Survival at 5 years for the N0 Stage patient was 40%, whereas it was about 20% for those with clinically palpable nodes. Patients with exophytic tumors and lesions which regressed completely within 8 weeks following irradiation had a significantly better 3-year survival and local control than those with nonexophytic tumors and with tumors which had incompletely regressed after irradiation. Radiotherapy remains the treatment of choice for the small tumors (T1, T2) but the association of radical surgery with pre- or postoperative radiotherapy should be considered for advanced disease.

Pi meson radiotherapy for advanced head and neck neoplasms: preliminary results.

Under the auspices of the University of New Mexico Cancer Research and Treatment Center, trials are under way at the Los Alamos Meson Physics Facility to evaluate the effects of pi meson irradiation on locally advanced human tumors. This paper summarizes the preliminary results in patients with locally advanced head and neck tumors treated under Phase 1 and Phase II studies. A total of 26 patients were treated between June 1977 and May 1979 with a minimum follow-up of 9 months and a maximum follow-up of 33 months. Sites of disease included the oropharynx in 10 cases (base of tongue in 7, tonsil in 2, and pharyngoepiglottic fold in 1), the supraglottic larynx in 4, the nasopharynx in 5, the oral cavity in 4, the hypopharynx in 2, and the sublingual salivary gland in 1. Twelve of the 26 patients are alive, and 10 survive with no evidence of disease. Doses employed ranged from a minimum of 1,000 peak pion rad in 7 fractions over 9 days to a maximum of 5,4000 peak pion rad in 51 fractions of 89 days. The minimum dose employed for any patients treated with peak pions alone was 3,000 rad. These data are analyzed according to dose, sit, histology, tumor response, local control, and survival. Results from these cases form the basis of the Phase III randomized trials for advanced squamous-cell carcinomas of the head and neck, which are currently in progress.

Difficult indications for partial laryngectomy.

Difficult indications for certain partial laryngectomies are presented. Anatomically, the difficulties stem from the thyroid cartilage and from the paraglottic space in which invasion (difficult to determine) is contradictory for partial surgery. The principal objective is the cure of the laryngeal cancer all in maintaining laryngeal function. The surgeon must conserve a 'minimal' arytenoid unit' (the whole formed by the pharyngoepiglottic fold, the aryepiglottic fold, the arytenoid and the corresponding cord). Other difficulties not carcinogenic are found: physical conditions, social and professional situation, and preexisting local problems (associated laryngocel or previous vocal palsy). Finally, carcinogenic difficulties can be seen: the situation of the tumor, the rapidity of its evolution, anatomopathologic type, presence of nodes and metastases and previous physiotherapy and chemotherapy.

ROENTGENTHERAPY IN CANCER OF THE HYPOPHARYNX

The prognosis for cancer of the hypopharynx is poor because tumors occurring in this site are usually of an ulcerating and destructive nature. Complications, such as infection, involvement of the cartilage and sometimes considerable extension to the surrounding structures, make these lesions difficult to cure. ANATOMIC CLASSIFICATION The upper or membranous portion of the hypopharynx includes the whole aryepiglottic fold and the thyrohyoid membrane. The upper limit is the pharyngoepiglottic fold and the lower limit, approximately, the mucous fold of the superior laryngeal nerve. Radiographically, this part is projected between the hyoid bone and the superior border of the thyroid cartilage. The lower or osteocartilagenous portion of the hypopharynx is deep, narrow and hidden. It is limited laterally by the thyroid lamina and medially by the arytenoid and the cricoid cartilages covered by muscles and fascia. The distinction between the two parts is of particular significance when one considers the

THE PIRIFORM SINUS: ANATOMIC AND CLINICAL OBSERVATIONS, WITH A REVIEW OF THE LITERATURE

The piriform sinus, also termed recessus, or fossa, pyrifomis, is occasionally described as being part of the larynx, but, since it lies outside of that organ, is, strictly speaking, part of the hypopharynx. It appears as a deep depression between the cricoid and arytenoid cartilages and the posterior surface of the thyroid cartilage on each side of the larynx. It is situated beneath the pharyngoepiglottic fold. Its mucous membrane laterally adjoins the posterior surface of the ala of the thyroid cartilage. In its anterior part is a low fold, the plica nervi laryngei superioris, which is produced by the internal branch of the superior laryngeal nerve and which runs downward and medially (fig. 1). The piriform sinus is limited above by the hyoid bone and below by the lower border of the cricoid cartilage. In many persons, especially those who are not too obese, one can see a white line