Biomedical subjects
L D Holinger
Publications and source records attributed to L D Holinger.
Bilateral abductor vocal cord paralysis in Charcot-Marie-Tooth disease.
This report descirbes the unusual association of bilateral abductor vocal cord paralysis (BAbVCP) and Charcot-Marie-Tooth disease in a boy and his natural mother who have been followed for eight years. The boy initially presented with life-threatening respiratory distress at age ten years; BAbVCP was documented by direct laryngoscopy. Mirror laryngoscopy confirmed BAbVCP in the mother. Neurological diagnosis was made by history, physical examination, electromyography, and nerve conduction velocity studies. The BAbVCP may represent an additional genetic marker within the spectrum of heredodegenerative disorders. Of clinical importance is examination of voice and respiratory symptomatology of patients with heredodegenerative diseases and neurological work-up of patients with familial vocal cord paralysis. Further genetic and clinical studies of X cranial nerve involvement in heredodegenerative disorders are warranted.
Lymphoid hyperplasia of larynx simulating neoplasia.
A rare case of lymphoid hyperplasia of the adult larynx (hyperplasia of the laryngeal tonsil) is reported. While this benign lesion recurred following surgical excision, the patient has been followed for more than two years without additional therapy and is asymptomatic. Seven additional cases of laryngeal lymphoid hyperplasia in the English literature are reviewed. The problems related to inadequate sampling (biopsy) and the histologic criteria for diagnosis are emphasized. To define the pathogenesis and ultimate biologic potential of this lesion, more cases must accrue and be studied with a long follow-up.
Etiology of stridor in the neonate, infant and child.
Of 219 patients whose primary presenting symptom was stridor, 150 were males, 69 were females. All were under 2 1/2 years of age; more than half were four months of age or younger. Congenital anomalies caused stridor in 191 (87.2%). Congenital laryngeal anomalies accounted for the stridor in 132 (60.3%); there were 35 (16.0%) patients with congenital tracheal anomalies, 11 (5.0%) with congenital bronchial anomalies, 12 (5.5%) with infectious conditions, 12 (5.5%) with internal laryngeal trauma and 15 (6.8%) patients with other conditions. The cause of stridor was undetermined in two patients. Sixteen vascular anomalies were diagnosed and classified according to the part of the tracheobronchial tree which was involved. Twenty-six patients required tracheotomy. Fifty-eight (26.5%) were referred with an erroneous presumptive diagnosis for which they were being treated. The mean length of time from onset of symptoms to determination of the correct diagnosis by endoscopy was four months; it varied from one day to 16 months. The importance of early endoscopy for the diagnosis of conditions causing stridor cannot be overemphasized. The occurrence of more than 1 anomaly in 99 (45.2%) of the 219 patients demonstrates the importance of complete endoscopic examination of all patients with stridor.
Treatment of severe subglottic stenosis without tracheotomy: a preliminary report.
Subglottic stenosis in neonates, infants and children is one of the most challenging problems confronting the pediatric otolaryngologist today. Small patients with congenital or acquired stenosis were enough to require tracheotomy must undergo repeated endoscopic procedures or laryngotracheal reconstruction; weeks, months, or years may be required to attain a lumen large enough to permit decannulation. During 1981, six infants and children with severe subglottic stenosis were managed without tracheotomy. The surgical technique employed involves endoscopic excision of the offending subglottic tissue using the CO2 laser and suspension microlaryngoscopy. Intraoperative intubation is avoided by using an insufflation technique for general anesthesia which permits unobstructed visualization of the larynx, thereby avoiding laryngeal trauma and edema.
High frequency ventilation through a small catheter for laser surgery of laryngotracheal and bronchial disorders.
One-lung and two-lung high frequency ventilation (HFV) through a 2-mm internal diameter catheter was evaluated in 22 patients during endoscopic laser excision of stenotic lesions of larynx, trachea, and bronchi. High frequency ventilation at 80 to 250 breaths per minute using air during two-lung HFV and using air-oxygen at an inspired oxygen concentration of 25% during one-lung HFV maintained adequate alveolar ventilation and oxygenation in all patients. The use of HFV through a catheter allowed continuous control of ventilation and provided maximal surgical exposure for endoscopic laser surgery. The continuous outflow of HFV gases through the endoscope also prevented lung contamination with blood and debris. The potential of HFV polyvinylchloride catheter ignition by laser was also evaluated in the laboratory during continuous flow of air-oxygen and oxygen-nitrous oxide. The laser ignited polyvinylchloride tubes in all the mixtures of oxygen and nitrous oxide within 3 to 7 seconds. Oxygen at 30% mixed with nitrogen 70% was safe and all such tubes were not ignited by the laser. The ability of HFV to provide adequate oxygenation during endoscopic laser surgery using air-oxygen at an FiO2 below 30% also avoids the hazard of catheter and airway fire.
Cleft larynx with airway obstruction.
Cleft larynx is a rare congenital anomaly becoming recognized and reported with increasing frequency. While it is most commonly associated with aspiration in newborns, airway obstruction can occur. We report two cases of upper airway obstruction due to a soft tissue mass related to the cleft. Since endoscopic findings of cleft larynx are subtle and easily overlooked, the technique of direct laryngoscopy is extremely important. In addition to recognition of the condition, embryology and treatment are also discussed.
Management of infants with prenatal ultrasound diagnosis of airway obstruction by teratoma.
We report a case of a cervical teratoma that was diagnosed prenatally. In anticipation of potential upper airway obstruction, resources were mobilized to the operating room at the time of planned cesarean section. The neonate developed respiratory distress, and her airway was secured. There was no evidence of cerebral anoxia initially, and she is currently thriving with no central or peripheral neurologic defects. As prenatal diagnosis by ultrasound becomes more refined, the otolaryngologist will play an increasing role in perinatal decision-making and anticipated emergencies at the time of delivery. Airway obstruction of various causes will be the most urgent problem.
Bronchial casts in children.
Bronchial casts were found in four children during a 2-year period at the Children's Memorial Hospital. These four children represent 0.2% of the 1,943 endoscopic cases during that time. Thirty other cases of bronchial casts have been reported previously in children 9 years of age or younger, only 12 of which were not associated with cystic fibrosis. Casts may be a complication of many diseases; cystic fibrosis, asthma, bronchitis, allergic bronchopulmonary aspergillosis, and bronchocentric granulomatosis are the most common. With the exception of cystic fibrosis, these diseases may all have an allergic pulmonary reaction as the underlying cause. In all four cases reported here, the diagnosis was made at endoscopy because the clinical picture is not dissimilar from that of bronchial foreign bodies. Management includes endoscopic removal of the cast, chest physical therapy with nebulized acetylcysteine, and an evaluation to determine the underlying condition.
Congenital laryngeal anomalies associated with tracheal agenesis.
Forty-eight cases of tracheal agenesis have been reported to date. Previous authors have studied gross postmortem laryngeal specimens. Of 37 cases wherein laryngeal findings were mentioned, only 14 were reported to be abnormal. This report details two more cases of tracheal agenesis and includes a detailed histopathologic study of the laryngeal anomalies by serial horizontal section. Although one of these specimens appeared normal at autopsy, both were found to have several abnormalities when studied microscopically in horizontal section. Both have an elliptical cricoid cartilage, an abnormality originally discovered by one of us (G.F.T.) using the same technique.
New endoscope for (laser) endoscopic diverticulotomy.
In the United States, traditional treatment of the hypopharyngeal (Zenker's) diverticulum has been single stage transcutaneous diverticulectomy. Complications following this procedure include mediastinitis, vocal cord paralysis, esophageal stenosis, fistula, and recurrent or persistent diverticulum. Endoscopic diverticulotomy, widely used throughout Europe, is relatively straightforward and efficacious. Transoral management of these diverticulae has allowed symptomatic relief with a low incidence of complications. A new endoscope has been developed to facilitate use of the carbon dioxide laser for endoscopic diverticulotomy. The instrument combines the characteristics of the Dohlman endoscope (bilateral distal slots) with a wider proximal end for microscopic endoscopy, a smoke evacuator channel, a fiberoptic light carrier, and a handle adaptable for suspension microendoscopy.
Laryngotracheal reconstruction for subglottic stenosis in children.
The experience with laryngotracheal reconstruction in 20 children in Chicago is reviewed. Nine of the 20 children (45%) operated upon had congenital subglottic stenosis. Ten (50%) had acquired stenosis. One child was classified as having combined types. All patients underwent laryngotracheal reconstruction with autogenous costal cartilage grafts. Eight patients had both anterior and posterior costal cartilage grafts with stent insertion. One had a posterior costal cartilage graft only. Sixteen of the 20 children (80%) have been decannulated. Midtracheal or lower tracheal disease concomitant with laryngotracheal stenosis is an indication that endoscopic management of severe subglottic stenosis is likely to fail. Early laryngotracheal reconstruction is indicated for patients with a high likelihood of failure of endoscopic management and for those with severe cricoid cartilage deformities. Our results support the use of laryngotracheal reconstruction as an alternative to conservative (endoscopic) management of severe subglottic stenosis in carefully selected patients.
Prolapse of the laryngeal ventricle.
Many varied lesions may protrude into the laryngeal lumen from between the true and false vocal cords. These protrusions can be precisely diagnosed only by biopsy. Prolapse of the laryngeal ventricle is one of these lesions; it is a distinct clinicopathologic entity, a primary lesion unrelated to other laryngeal or systemic disease. Eversion of the ventricle (or saccule) is a similar protrusion that is secondary to pulsion or traction by an associated laryngeal lesion. Other lesions that may produce similar clinical findings and gross appearance include benign tumors, cysts, and, rarely, squamous cell carcinoma. Biopsy is therefore mandatory to plan rational treatment. A review of 26 patients who had been diagnosed as having prolapse resulted in the reclassification of 20 cases of prolapse and six cases of eversion. Prolapse is possibly unrelated etiologically to cough, or chronic laryngeal or respiratory tract infection. The histopathologic data suggest further that prolapse is a result of fatty infiltration, edema, and inflammation of the periventricular tissue above the ventricle, which cause the tissue to enlarge and protrude into the laryngeal lumen from between the true and false vocal cords.
Congenital laryngeal lesions: pathology study using serial macrosections and review of the literature.
This description of congenital laryngeal lesions is presented with a focus on the information derived from the specimens collected for the Laryngeal Development Laboratory at the Children's Memorial Hospital in Chicago from 1975 to 1992. During this period, 115 laryngeal specimens were obtained, 33 of which were found to have congenital laryngeal anomalies. Two specimens are thought to have laryngomalacia; 4, thyroid cartilage anomalies; 1, absence of the epiglottis; and 29, cricoid cartilage deformities. Of the cricoid cartilage deformities, 1 had large anterior lamina; 1, generalized thickening; 8, elliptical shape; 4, flattened shape; 8, occult cleft larynx; 1, partial cricoid cleft; 3, complete cricoid cleft; and 8, fragmented or distorted shape. Some specimens have more than one type of anomaly.
Congenital tracheal anomalies: pathology study using serial macrosections and review of the literature.
This description of congenital tracheal lesions is presented with a focus on the information derived from the specimens collected for the Laryngeal Development Laboratory at the Children's Memorial Hospital in Chicago from 1975 to 1992. During this period, 115 laryngotracheal specimens were obtained, 22 of which were found to have congenital tracheal anomalies. Six specimens were determined to have tracheomalacia, including one with primary tracheomalacia and five with secondary tracheomalacia: three were associated with tracheoesophageal fistula and two with aberrant innominate artery. Thirteen specimens had a trapped first tracheal arch; one, complete tracheal rings; and two, tracheal cartilaginous sleeve. Three specimens had tracheal agenesis, and three, tracheoesophageal fistula. Some specimens have more than one tracheal anomaly. Sixteen patients also had anomalies of other systems.
Histopathologic fundamentals of acquired laryngeal stenosis.
Acquired laryngeal stenosis is the most serious long-term complication of endotracheal intubation in children. Employing the whole-organ serial section technique, the sequence of histopathologic changes leading to stenosis was studied. Ulceration occurs when an endotracheal tube causes mechanical abrasion and/or induces pressure necrosis on the laryngeal mucosa. Secondary healing of ulceration produces granulation tissue and subsequent fibrous scar tissue. Most exuberant granulation tissue resolves without sequelae, but some becomes firm, almost avascular fibrous scar tissue. The accumulation of submucosal fibrous tissue may decrease the size of the glottic or subglottic lumen. Contraction of scar tissue causes a distortion of glottic and subglottic laryngeal complex, leaving a reduced and irregularly shaped glottic and subglottic lumen. Submucosal mucous gland hyperplasia directly reduces the inner diameter of the airway. Finally, compromise of the laryngeal lumen may occur when the duct of a mucous gland is obstructed by scarring resulting from intubation: mucus accumulates in the dilated duct, producing a ductal cyst.
Treatment of infantile bilateral nasal valve stenosis using an endotracheal tube stent.
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