Supraglottic Area Research Articles

Sublingual and Supraglottic Haemorrhage as a Complication of Warfarin Therapy

Anticoagulant-induced haemorrhage in the upper airway is rare, but it can be life threatening if airway obstruction develops. Treatment is mainly conservative. Urgent control of airway and coagulopathy are the essential of management. Vitamin K1 or combination of fresh frozen plasma and vitamin K1 should be used for reversal of the coagulopathy. In this report, two elderly patients were reported to have oral anticoagulant (warfarin)-induced haemorrhage in the sublingual and supraglottic areas.

Comparison between Fasciocutaneous and Jejunum Flaps in Pharyngolaryngoesophageal Reconstruction

Comparison between Fasciocutaneous and Jejunum Flaps in Pharyngolaryngoesophageal Reconstruction

Subglottic stenosis induced by extranodal mucosa-associated lymphoid tissue lymphoma

Mucosa-associated lymphoid tissue (MALT) lymphoma is usually associated with a chronic inflammatory disease or autoimmune disorders from which lymphoid tissue of MALT type arises as a prerequisite for lymphoma proliferation. Primary hematopoietic neoplasms of the larynx are rare. MALT lymphomas of the larynx are believed to arise from preexisting or acquired lymphoid tissue of the upper airway which is documented in the supraglottic region. Therefore, these are mainly located in the supraglottic and glottic areas, with only a few reported in the subglottic region. We report on a 50-year-old woman with a hoarseness, stridor, and developing exertional dyspnea. On indirect laryngoscope, multiple nodular lesions with smooth surface over the subglottis with subglottic steonsis was found. The biopsy confirmed the diagnosis of a MALT lymphoma. We hope to promote awareness and consideration of MALT lymphoma in the differential diagnosis in subglottic steonsis.

Nasotracheal intubation using the Airtraq® optical laryngoscope in patients with a difficult airway

To the Editor, We were interested in a recently published case report describing application of the Airtraq optical laryngoscope (Airtraq) for nasotracheal intubation (NTI) in a patient with a predicted difficult airway who was undergoing oral surgery. The authors are to be congratulated on their successful airway management in this challenging case. However, topical anesthesia was performed on only the naris and nasopharynx. In our experience, topical anesthesia of the trachea is also important for successful tracheal intubation and to ensure comfort of the awake patient. Moreover, insertion of a MADgic laryngotracheal atomizer (MAD-LTA) (Wolfe Tory Medical Inc., Salt Lake City, UT, USA) through the oral and nasal cavities for topical anesthesia of the supraglottic, glottic, and infraglottic areas can be performed quite easily under the visual field of the airway provided by the Airtraq. This technique is well tolerated by the awake sedated patient, possibly due to less stimulation of the oropharyngolaryngeal structures during laryngeal exposure using the Airtraq, as it does not require a ‘‘line of sight’’ to visualize the airway anatomy. In cases where there was difficulty in directing the nasotracheal tube tip into the glottis under direct vision with the Airtraq, the authors used a flexible nasotracheal tube rather than a preformed tube to insert the fibreoptic bronchoscope (FOB). Preformed nasotracheal tubes are very useful for patients undergoing head and neck surgery because they are easy to secure, they provide convenient surgical access, and they may reduce pressure on the nares. We previously reported methods to improve use of preformed nasotracheal tubes during FOB-guided NTI. Our experience suggests that difficulty in directing the tube tip into the visualized glottis can be challenging when NTI is performed with the Airtraq, especially for pediatric patients. To address this problem, we have used all the techniques described in the recent case report. In some cases, we have found external laryngeal manipulation to be useful in locating the lateral tube tip. Although the nasal version Airtraq provides additional space to facilitate passage of Magill forceps in the absence of a posterior tubeguiding channel, the greater distal angulation of its blade may render their use very awkward. Furthermore, use of Magill forceps can occasionally result in cuff damage. Combined use of the Airtraq and a FOB can enable successful NTI in patients with difficult airways, but disadvantages of this method include the need of two experienced anesthesiologists during tracheal intubation and complex cleaning and sterilization procedures after tracheal intubation. In our practice, the Airtraq and a FOB are used in combination in any situation where the operator is unable to visualize the glottis by the viewfinder, either with or without the epiglottis, i.e., either a CormackLehane grade 3 or grade 4 view via the Airtraq. If only the nasotracheal tube tip is excessively posterior or lateral to the glottis under the Airtraq visualization, we prefer to use a cuff inflation technique to align the tube tip with the glottis. When only a Cormack-Lehane grade 2 view is obtained using the Airtraq or when the glottis is off-centre of the viewfinder, we have recently combined use of the Airtraq and the Eschmann Tracheal Tube Introducer (gum elastic Fu S. Xue and Xu Liao contributed equally to this work.

The Black Sombrero: A Helpful Landmark in Axial Imaging Evaluation of the Larynx and Hypopharynx

Computed Tomograpy (CT) scan and Magnetic Resonance Imaging (MRI) evaluation of the larynx and hypopharynx can be tricky for the untrained eye. We discuss a peculiar pattern of the supraglottic airway at the level of the base of the epiglottis seen on axial CT and MR images, resembling a “black hat” or a “black sombrero.” The level of the base of the epiglottis also corresponds to that of the hyoid bone, where two valuable hypopharyngeal sub-sites are visible- the pyriform sinuses and the posterior hypophayngeal wall.
 
 A hat has basically two parts, an apical convex crown and a basal horizontal brim. (Figure 1.A) Correlating the hat’s appearance on axial CT and MR imaging, the hat appears black due to the presence of air at the supraglottic level wherein the crown is positioned anteriorly and the brim positioned posteriorly. (Figure 1.B)
 
 The top-most convex part of the crown corresponds to the base of the epiglottis. Anterior to it is the pre-epiglottic fat plane and the body of the hyoid bone. The crown is also flanked by the paraglottic fat plane on both sides that appears hypodense (dark) on CT and hyperintense (bright) on T1 MRI. On the other hand, the posterior-most portion of the hat’s brim abuts the posterior hypopharyngeal wall - laterally outlining the pyriform sinuses on each side. The area where the crown joins the brim corresponds to the aryepiglotic folds that are delineated laterally by the medial walls of the pyriform sinuses while its medial aspects correspond to portions of the supraglottis. (Figure 2)
 The size and configuration of the hat varies and can range from one with a big crown and a small brim (resembling a “bowler” or “derby hat”) to one with a tall crown and a floppy brim (resembling a “Mexican sombrero”). (Figures 2, 3) Infiltrating tumors and inflammatory processes can distort the hat’s usual symmetric configuration, and can be useful in determining possible sites of inflammation or infection, tumor origin, and spread to hypopharyngeal and supraglottic structures, as the hat’s center represents a potential space at the supraglottic area devoid of any soft tissue structures. (Figure 4)
 In radiology, “the bowler hat sign” and “Mexican hat sign” have been used to describe gastrointestinal polyps.1,2,3 The former “is produced by the acute angle of attachment of the polyp to the mucosa” while the latter “consists of two concentric rings and is produced by visualizing a pedunculated polyp head-on.”1 The “Mexican hat sign” has also been used to describe osmotic demyelination on MRI.4
 
 To our knowledge, these terms have not been applied to the interpretation of supraglottic and hypopharyngeal CT and MRI axial images. Recognition of the “Black Sombrero” pattern can be helpful in understanding the anatomic relationship of the supraglottic and hypopharynx structures on axial CT and MR imaging, particularly in the evaluation of supraglottic and hypopharyngeal tumor spread.

Expression of Hypoxia Inducible Factor-1α and Its Significance in Laryngeal Carcinoma

This study examined levels of hypoxia inducible factor-1α (HIF-1α) protein in 40 laryngeal squamous cell carcinoma specimens using immunohistochemistry. Correlations between HIF-1α immunoreactivity and patient age, tumour lymph node metastasis stage, histological grade (extent of differentiation), and alcohol and smoking history were evaluated. Of the tumour tissues obtained, 35 (87.5%) were located in the glottic area and five (12.5%) in the supraglottic area. All patients were male and aged between 35 and 71 years; 12 (30.0%) presented with lymph node metastases, 24 (60.0%) had cancer classified as T(1) or T(2), and 16 (40.0%) as high clinical stage (T(3) or T(4)). The pattern of HIF-1α protein localization in tumour tissues, when present, was mixed nuclear/cytoplasmic, with positive HIF-1α expression in 27 patients (67.5%). Differences in HIF-1α levels in samples from different tumour stages and in those with lymph node-positive versus lymph node-negative cancers were statistically significant.

The Black Sombrero: A Helpful Landmark in Axial Imaging Evaluation of the Larynx and Hypopharynx

Computed Tomograpy (CT) scan and Magnetic Resonance Imaging (MRI) evaluation of the larynx and hypopharynx can be tricky for the untrained eye. We discuss a peculiar pattern of the supraglottic airway at the level of the base of the epiglottis seen on axial CT and MR images, resembling a “black hat” or a “black sombrero.” The level of the base of the epiglottis also corresponds to that of the hyoid bone, where two valuable hypopharyngeal sub-sites are visible- the pyriform sinuses and the posterior hypophayngeal wall.   A hat has basically two parts, an apical convex crown and a basal horizontal brim. (Figure 1.A) Correlating the hat’s appearance on axial CT and MR imaging, the hat appears black due to the presence of air at the supraglottic level wherein the crown is positioned anteriorly and the brim positioned posteriorly. (Figure 1.B)   The top-most convex part of the crown corresponds to the base of the epiglottis.  Anterior to it is the pre-epiglottic fat plane and the body of the hyoid bone. The crown is also flanked by the paraglottic fat plane on both sides that appears hypodense (dark) on CT and hyperintense (bright) on T1 MRI. On the other hand, the posterior-most portion of the hat’s brim abuts the posterior hypopharyngeal wall - laterally outlining the pyriform sinuses on each side. The area where the crown joins the brim corresponds to the aryepiglotic folds that are delineated laterally by the medial walls of the pyriform sinuses while its medial aspects correspond to portions of the supraglottis. (Figure 2) The size and configuration of the hat varies and can range from one with a big crown and a small brim (resembling a  “bowler” or “derby hat”) to one with a tall crown and a floppy brim (resembling a “Mexican sombrero”). (Figures 2, 3) Infiltrating tumors and inflammatory processes can distort the hat’s usual symmetric configuration, and can be useful in determining possible sites of inflammation or infection, tumor origin, and spread to hypopharyngeal and supraglottic structures, as the hat’s center represents a potential space at the supraglottic area devoid of any soft tissue structures. (Figure 4) In radiology, “the bowler hat sign” and “Mexican hat sign” have been used to describe gastrointestinal polyps.1,2,3 The former “is produced by the acute angle of attachment of the polyp to the mucosa” while the latter “consists of two concentric rings and is produced by visualizing a pedunculated polyp head-on.”1 The “Mexican hat sign” has also been used to describe osmotic demyelination on MRI.4   To our knowledge, these terms have not been applied to the interpretation of  supraglottic and hypopharyngeal CT and MRI axial images. Recognition of the “Black Sombrero” pattern can be helpful in understanding the anatomic relationship of the supraglottic and hypopharynx structures on axial CT and MR imaging, particularly in the evaluation of supraglottic and hypopharyngeal tumor spread.

Bedside ultrasonography as a safe and effective tool to diagnose acute epiglottitis

Acute epiglottitis is a true airway emergency in the emergency department (ED). The patient may appear very toxic and rapidly progress to respiratory distress and life-threatening condition. The inflammatory process includes not only epiglottis but also the rest of the supraglottic area including the vallecula, aryepiglottic folds, and arytenoids. Soft tissue swelling over this windpipe area can be very dramatic. The criterion standard of diagnosis is direct inspection of cherry red and swollen epiglottis by laryngoscopy in the operation room with immediate access to anesthetists or ear, nose, and throat specialists. However, before the patients are well prepared, the clinical condition may critically go downhill; and any intention to visualize the throat can result in severe and fatal airway spasm. Thumbprint sign on lateral radiography of neck is typical, but it may be extremely risky to let a patient leave the consulting room for the study if respiratory distress has developed. We demonstrate a safe and practical way to investigate the epiglottis by bedside ultrasonography to visualize the "alphabet P sign" in a longitudinal view through thyrohyoid membrane by emergency physician in the ED.

Belastungsabhängige Dysphonie, rezidivierende Pleuropneumonie und supraglottische Raumforderung

Urbach-Wiethe syndrome (hyalinosis cutis et mucosae) is an autosomal-recessive inherited disease. It often presents with typical symptoms such as skin lesions (especially in the face and neck area), dyspnea, and maldigestion. Hoarseness is a leading symptom in young children. These manifestations are caused by the assimilation of glycoproteins in mesenchymal tissue. Our case report shows that hoarseness does not necessarily appear only in children, but can also appear later. Furthermore, the assimilation of glycoproteins in the supraglottic area may also cause dysphonia. Due to the varied features of this disease, interdisciplinary check-ups are necessary at regular intervals.

Severe bradycardia during suspension laryngoscopy performed after tracheal intubation using a direct laryngoscope with a curved blade -A case report-

There are a few reports about bradycardia or asystole caused by direct laryngoscopy. However, we encountered severe bradycardia in response to suspension laryngoscopy for laryngeal polypectomy after safely completing tracheal intubation using a direct laryngoscope with a curved blade. The tip of the curved blade of the direct laryngoscope is positioned at the vallecula (between the base of the tongue and the pharyngeal surface of the epiglottis) during tracheal intubation, while the blade tip of the suspension laryngoscope lifts the laryngeal surface of the epiglottis or supraglottic area during surgery. Therefore, suspension laryngoscopy can be said more vagotonic than curved-blade direct laryngoscopy. Because of the possibility of bradycardia induced by suspension laryngoscopy, clinicians must be careful about severe bradycardia even after safely completing intubation using direct laryngoscopy.

Laryngeal Lipoma Associated with Diffuse Lipomatosis: Case Report and Literature Review

Lipomas are benign mesenchymal tumors that are often found in the head and neck. Intrinsic lipomas of the larynx and supraglottic area are rare, as fewer than 115 cases have been reported in the literature; almost all of these occurred in isolation. We report a case of a laryngeal lipoma that was associated with diffuse systemic lipomatosis. The tumor was successfully removed via an endoscopic laser resection. To the best of our knowledge, this is only the second case of laryngeal lipoma associated with lipomatosis to be reported in the English-language literature. We also review the literature on head and neck lipomas.

Wznowy u pacjentów leczonych operacyjnie z powodu raka krtani

The aim of the present study was to investigate the recurrence prevalence in patients with laryngeal squamous cell carcinoma (LSCC) underwent surgery as primary treatment. The assessed group consisted of 148 patients with operable LSCC underwent surgery as primary treatment between 1999–2002. Surgery was performed in all cases. Total laryngectomy was performed in 107 (72.3%) patients and laser endoscopic tumor resection was performed in 41 (27.7%) patients. Local recurrence occurred in 18 (12.2%) patients, nodal recurrence in 12 (8.1%) and both and/or remote metastases in 6 (4%) patients. Altogether, recurrence was present in 36 (24.3%) patients and 111 (75.7%) patients had no symptoms of recurrence. Recurrence prevalence in 3-year follow-up – prevalence of recurrence significantly increased with tumor's T feature (p = 0.04), N feature (p = 0.03), progression of clinical stage (p = 0.008) and histological malignancy G stage (p = 0.01). Recurrence prevalence in 5-year follow-up – prevalence of recurrence significantly increased with tumor's T feature (p = 0.02), N feature (p = 0.01), progression of clinical stage (p = 0.003) and histological malignancy G stage (p = 0.002). Tumors localized in glottic area had less recurrences than those localized in supraglottic area (p = 0.05). There were no significant dependence between recurrence type (local or nodal) and tumor's clinicopathological features. Multiple factor analysis with logistic regression model did not reveal simultaneous influence of many variables on recurrence's presence and type. Using multiple factor analysis with Cox's regression model it was proved that recurrence presence (p<0.00001) is a significant independent prognostic factor in the analyzed group of patients with laryngeal carcinoma in 3-year follow-up. Recurrence prevalence depends on localization, systemic progression stage, clinical progression stage, cervical lymph nodes state and histological malignancy stage of tumor. Patients with local recurrence have statistically significantly worse prognosis than patients with no recurrence. Recurrence presence is significant independent prognostic factor in 3-year follow-up.

A new video laryngo-pharyngoscope with shape-holding coiled tube and surgical forceps: A preliminary study

Objectives We developed a new video laryngo-pharyngoscope with a shape-holding coiled tube and examined its effectiveness in some patients. Methods The video laryngo-pharyngoscope is designed to inspect the pharynx and larynx transorally and to perform surgical manipulations. The scope consists of a coiled tube, a grip with trigger connected to the forceps and a CCD Camera with a battery. The stainless coiled tube of the scope is flexible but shape-holding, so that its shape can be changed by hand with the characteristic that the new orientation remains invariable during both inspection and operation in the pharynx and larynx. After a local anesthesia, the operator holds the scope in one hand and pulls the patient's tongue by the other hand. The operator then inserted the scope transorally while monitoring video images that were wirelessly transferred to the display to ensure that the forceps has reached the area of interest and treated lesions successfully. Results Using the scope, we successfully examined the upper airway lesions and removed foreign bodies from the pharynx and performed both resection of a benign tumor and taking a biopsy of a malignant tumor from the pharynx and larynx. But, we could hardly remove vocal fold polyps because of the structural limitation of the scope. Conclusions We demonstrated that the new video laryngo-pharyngoscope can be used safely and successfully in the inspection and removal of lesions in the oropharynx and supraglottic area of the larynx and will be a useful tool for minimally invasive office-based surgery.

The Pentax-AWS for airway obstruction after tracheal extubation

We report two cases of airway obstruction occurring after tracheal extubation, in which the cause of airway obstruction could immediately be confirmed, and re-intubation carried out, using the Pentax-AWS videolaryngoscope (Pentax, Tokyo, Japan). In the first, a middle-aged woman was scheduled for laparoscopic cholecystectomy. After induction of anaesthesia and neuromuscular blockade, the trachea was intubated. At the end of uneventful operation, 50 mg flurbiprofen axetil, a non-steroidal anti-inflammatory drug, was injected intravenously. The trachea was extubated after the patient regained consciousness and responded to verbal command. Shortly later, she complained of dyspnoea and acute airway obstruction occurred. A laryngeal mask airway was inserted while a new tracheal tube was being prepared, but obstruction continued. As rashes had appeared on her chest wall, anaphylactic reaction to the non-steroidal anti-inflammatory drug was suspected. While treatment was being started for possible anaphylaxis, the laryngeal mask was removed and the Pentax-AWS inserted, to observe the upper airway. Oedema of the glottis was confirmed on the videoscreen. The trachea was re-intubated, by advancing a tracheal tube which was attached to the Pentax-AWS. In the second case, a middle-aged man was scheduled for laryngomicrosurgery. After uneventful induction of anaesthesia and tracheal intubation, the surgeons resected laryngeal tumour without difficulty and reported that there was no oedema or bleeding. The trachea was extubated after the patient had regained consciousness and responded to verbal command. Immediately after this, airway obstruction occurred and arterial haemoglobin oxygen saturation decreased to 70%. Insertion of the Pentax-AWS showed that the supraglottic area was now grossly oedematous. A tracheal tube which was attached to the Pentax-AWS was advanced into the trachea. In both cases, the trachea was extubated uneventually the next day. The shape of the Pentax-AWS blade is based on oropharyngeal anatomy, thus there is no need to place the patient’s head and neck to the ‘sniffing’ position, and little force is required to see the glottis [1, 2]. Consequently, insertion of the Pentax-AWS should be less stressful than with the Macintosh blade in awake patients. The videoscreen of the Pentax-AWS enables one to clearly see the cause of upper airway obstruction. In addition, because a tracheal tube is already attached to Pentax-AWS, it is possible to intubate the trachea immediately after confirming the cause of airway obstruction. We believe that the Pentax-AWS is potentially useful in patients with airway obstruction after tracheal extubation, when there is not enough time to give sedatives or local anaesthetics for insertion of a Macintosh laryngoscope, or to carry out fibreoptic intubation.

Clinical assessment of awake endotracheal intubation using the lightwand technique alone in patients with difficult airways

Background There is few study to determine whether the use of the lightwand technique alone could achieve effective, safe and successful awake endotracheal intubation (ETI), therefore we designed a prospective clinical study to systematically evaluate the feasibility, safety and efficacy of awake ETI using the lightwand alone in patients with difficult airways. Methods Seventy adult patients with difficult airways were enrolled in this study. After the desired sedation with fentanyl and midazolam, airway topical anesthesia was performed with 9 ml of 2% lidocaine, which were in order sprayed in three aliquots at 5 minutes intervals into the supraglottic (two doses) and laryngotracheal areas (one dose) using a combined unit of the lightwand and MADgic® atomizer. After airway topical anesthesia, awake ETI was performed using a Lightwand. Subjective assessments by patients and operators using the visual analogue scores (VAS), and objective assessments by an independent investigator using patients' tolerance and reaction scores, coughing severity, intubating conditions and cardiovascular variables were taken as the observed parameters. Results Of 210 airway sprays, 197 (93.8%) were successfully completed on the first attempt. The total time for airway spray was (14.6±1.5) minutes. During airway topical anesthesia, the average patients' tolerance scores were 1.7–2.3. After airway topical anesthesia, the mean VAS for discomfort levels that the patients reported was 6.5. Also airway topical anesthesia procedure was rated as acceptable and no discomfort by 94.3% of patients. The lightwand-guided awake ETI was successfully completed on first attempt within 29 seconds in all patients. During awake ETI, patients' reaction and coughing scores were 1.9 and 1.6, respectively. All patients exhibited excellent or acceptable intubating conditions. Cardiovascular monitoring revealed that changes of systolic blood pressure and heart rate at each stage of airway manipulations were less than 20% of baseline values. The postoperative follow-up showed that 95.7% of patients had no recall or slight memories of all airway instrumentation. The incidence of postoperative mild airway complications was 38.6%. Conclusion Alone use of the lightwand technique can achieve effective, safe and successful awake ETI in patients with difficult airways.

Correlation between radiological images and pathological results in supraglottic cancer

Radiological imaging plays an indispensable, complementary role to endoscopy in the pre-therapeutic assessment of laryngeal cancer. We evaluated the reliability of radiological imaging in determining the extent of cancer and surgical resection, by comparing the results of pre-operative computed tomography and magnetic resonance imaging with those for post-operative pathological analysis. Twenty-nine patients who had undergone laryngeal cancer surgery with a diagnosis of supraglottic cancer were reviewed. Imaging reliability was assessed for separate subunit regions of the supraglottic area, the glottic area and the cartilage. The false diagnosis rate for all subunits was 25 per cent. The rate of false diagnosis associated with overstaging was 21 per cent. The rate of false diagnosis associated with understaging was 4 per cent. In order to give the best chance of laryngeal preservation, especially in the case of false positive laryngeal subsites, computed tomography and magnetic resonance imaging should be combined with pre-operative endoscopy and intra-operative frozen section diagnosis.

Epidermal Growth Factor Receptor Tissue Expression Level as a Predictor for the Aggressiveness of HPV-associated Laryngeal Carcinoma

This study was designed to evaluate the frequency of human papilloma virus (HPV) infection in patients with laryngeal squameous cell carcinoma (LSCC) through identification of the viral DNA using PCR analysis and to determine the tissue levels of epidermal growth factor receptor (EGFR) as a trial tofind a relation between HPV infection, EGFR expression and clinicopathological findings in patients with LSCC. The study comprised 32 patients with suspected LSCC; 25 males and 7 females; with mean age 53.3±12.2; range: 25-72 years. All females and 5 males were non-smokers; while 20 males were smokers. Patients were subjected to full history taking and clinical examination. Direct laryngoscopy was performed under light general anesthesia in the operating room for evaluation of the larynx and the entire upper aerodigestive tract for accurate clinical staging according to TNM classification, to determine the full extent of the local spread of the tumor and to obtain tissue biopsy. Fresh tumor tissue specimens were divided into two parts, the first was studied and graded pathologically according to World Health Organization (WHO) classification and the second was stored at -70oC untilprocessed and examined by PCR technique for the presence of HPV-DNA and analyzedfor EGFR expression expressed as femto-mol/mg (fM/mg) protein. Squameous cell carcinoma was detected in 29 cases (90.6%) and 3 cases were excluded off the study; 21 patients (72.4%) had lesions clinically staged as stage I, while 3 (10.3%) and 5 (17.3%) had lesions of stages II and III, respectively. Patients had Stage I lesions were significantly (p<0.05) younger than patients with stage II and III lesions and 9 lesions were detected in non-smokers. Laryngoscopy defined 23 (79.3%) glottic lesions, 2 (6.9%) supraglottic and 3 (10.3%) subglottic lesions and one case (3.4%) had an extensive squamous cell carcinoma of the larynx involving the subglottic region,the glottis and the supraglottic areas. There were 21 (72.4%) polypoid lesions and 8 (27.6%) ulcerative lesions. According to WHO classification, 14 specimens were type 1, 9 specimens type 2 and 6 specimens were type 3. PCR could detect HPV-DNA in 16 (55.2%) specimens (viral specimens) and could not be detected in the other 13 specimens (non-viral cases). Four specimens of WHO type 1, 6 specimens ofWHO type 2 and 6 specimens of WHO type 3 were viral specimens. Mean tissue expression level of EGFR was 37.7±32.2 fM/mg protein and was significantly higher in viral (54.7±27.8 fM/mg protein) compared to non-viral cases (16.8±24.6 fM/mg protein) and in specimens of WHO type 2 and 3 compared to those of type 1. Moreover, there was a positive significant correlation between the pathological WHO types and presence of viral infection, (r=0.568, p=0.001) and the tissue expression levels of EGFR, (r=0.720, p<0.001) and a positive significant correlation between tissue expression of EGFR and the presence of viral infection, (r=0.595, P=0.001). Using the receiver operating characteristic (ROC) curve analysis judged by the area under the curve (AUC) to determine the specificity of the presence of HPV infection and tissue expression of EGFR as a predictor of cancer aggressiveness manifested as WHO pathological stage revealed that tissue expression of EGFR is more specific (AUC=0.731) than the presence of viral infection (AUC=0.583). It could be concluded that laryngeal infection with HPV may predispose to carcinogenesis through activation of certain growth factors as EGF and both were found significantly correlated with the aggressiveness of LSCC with the level of tissue expression of EGFR being a specific determinant of tumor aggressiveness manifested as pathologic stage.

A case of laryngeal ductal cyst: Antenatal diagnosis and peripartum management

Laryngeal mucous cysts are rare congenital malformations of the upper aero-digestive tract. We report one case of a ductal cyst developed in the supraglottic area. The diagnosis of an antenatal malformation was suspected on the basis of a hydramnios development during pregnancy. Ultrasound scan showed a cervical anechogen mass. This led to a fetal MRI which showed the cyst extension. A management of delivery had to be prepared due to the risk of air obstruction at the birth. The treatment consisted of a marsupialization of the cyst under laryngo-endoscopic surgery. Six months follow-up showed no recurrence.

Treatment of Supraglottic Airway Edema by Local Hyaluronidase

Treatment of Supraglottic Airway Edema by Local Hyaluronidase

Ocena skuteczności radioterapii niezaawansowanego raka krtani u chorych powyżej 70 roku życia

Evaluation of the results of radiotherapy in elderly patients with early laryngeal cancer, the relation between comorbidities and the overall treatment time, and the influence of treatment interruptions on the outcome of treatment. A clinical retrospective analysis of a group of 117 patients (over the 70 years old) with early laryngeal cancer was carried out. Patients were irradiated between the years 1980 and 2000 in the Centre of Oncology in Cracow. The analysed group consisted of 105 men (90%) and 12 women (10%). Patients' age ranged from 70 to 87 years, median - 73 years. Most of them had various comorbidities. Three different irradiation techniques and fractionation schemes were used according to the site, stage and grade of cancer: two oblique beams including the larynx with total dose of 60 Gy in 24 fractions (46 patients), two parallel opposing beams including the larynx and cervical lymph nodes with total dose of 60 Gy in 30 fractions (38 patients), and mixed photon-electron unilateral beam including the larynx with total dose of 60 Gy in 30 fractions (33 patients). The median follow-up was 48 months. During the follow-up period 78 patients (66.6%) died. Among them 29 patients (37.2%) died of laryngeal cancer, 6 (7%) patients of other malignancy, and 43 (55%) patients died of concomitant diseases without evidence of cancer. The actuarial 5/10-year overall survival (OS) and disease specific survival (DSS) were 51%/23% and 77%/68%, respectively. The overall tolerance of radiation therapy was good; only 3 patients had G3 early mucosal reaction, and 1 patient had G3 early skin reaction were observed. Comorbidities were not demonstrated to have statistically significant influence on DSS rate. In 6 (5.1%) from 117 patients complete tumor regression was not achieved after radiotherapy. During the follow-up period loco-regional relapse were observed in 27 patients (23.5%), and distant metastases in 2 patients (1.7%). Radiotherapy of the elderly patients with laryngeal cancer is effective and well tolerated method. Comorbidities do not significantly influence the treatment results. T stage, localization in supraglottic area, age over 73 years old, fractionation dose under 2 Gy and overall treatment time over 43 days are statistically significant negative prognostic factor for DSS rate.