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We report three cases of supraglottitis caused by Streptococcus pyogenes. In contrast to other reports of patients with severe clinical symptoms from supraglottitis with group A beta Streptococcus, our patients had mild disease that resolved rapidly and did not require endotracheal intubation. There is a broad spectrum of clinical illness with GABS supraglottitis.
This study is a retrospective review between 1976 and 1986 of 12 patients with T1(1) and T2(11) NO supraglottic cancers which were managed by a method that utilized planned preoperative radiotherapy (45-51 Gy) to the primary and bilateral necks. If adequate tumor response (greater than 75% reduction in size) was noted by laryngoscopy, therapy was completed at levels of 65-70 Gy to the primary. If a lesser tumor response was noted, the patient underwent supraglottic laryngectomy. Six patients completed primary radiotherapy (RT-RT) and six patients underwent supraglottic laryngectomy (RT-SG). There was evidence of residual tumor in three of six RT-SG patients. No tumor recurred at any site. Laryngeal function was preserved in all patients. Absolute survival was 58% at 67 months. This approach is oncologically sound and permits maximal laryngeal conservation.
Changes in the concepts regarding epiglottis have occurred over the last two decades. Supraglottis, once thought to occur exclusively in the pediatric population, is now recognized in adults. Supraglottis is a well-defined syndrome usually caused by a bacterial infection by Haemophilus influenzae type B. Recently, other organisms have been implicated as etiologic agents in cases of supraglottitis. Documented viral supraglottitis is very rare, and adult supraglottitis due to herpes simplex virus-I has not been reported to our knowledge.
Between January 1957 and June 1974, 173 patients with carcinoma of the supraglottic larynx were treated by an integrated approach at the University of California in San Francisco. The policy was to use radiotherapy or surgery alone for Stage I and II disease, radiotherapy combined with either supraglottic laryngectomy or total laryngectomy for resectable Stage III and IV disease, and radiotherapy alone for advanced unresectable disease. Control of the disease in the primary site was achieved in 92% of T1a, 88% of T1b, 80% of T2, 79% of T3 and 56% of T4 lesions. Of the 36 patients with late Stage I and resectable Stages III and IV disease treated by combined preoperative radiotherapy and supraglottic or total laryngectomy, the primary lesion was controlled in 33 (92%). Recurrent disease in the primary site after radiotherapy alone, when detected early, was usually controlled by subsequent surgery, whereas recurrent disease after surgery was not controlled by radiotherapy. Preservation of a functioning vocal apparatus was achieved in 44% of the patients whose primary lesion was controlled. Control of cervical lymph node metastasis was achieved in 71% of N1, 38% of N2, and 25% of N3 disease. No disease recurred in the radically dissected neck which received preoperative radiotherapy. Radiotherapy also reduced the incidence of subsequent neck disease in patients without cervical lymph node metastasis initially from 23% to 14%.
In 348 patients with supraglottic carcinoma 154 (44%) had palpable lymph nodes. Only 26% of the patients treated surgically showed histologically abnormal nodes in the neck. The incidence of regional metastasis increased to 33% including latent lymph node metastasis. There were 4 patients (5%) with positive nodes on histologic examination which had not been detected clinically (N0). In N1- and N2-patients, histologically positive nodes were found in 41% and 29%, respectively. A fixed node (N3) was nearly always a positive node. Postoperative TNM-classification is very important in terms of prognosis of the supraglottic carcinoma. The presence of metastasis in regional lymph nodes decreased the 5-year-survival rate from 64% to 43%. Because of the high frequency of lymphatic metastases of the supraglottic carcinoma, the aim of radical surgery should include the removal of regional metastases and of the potential bilateral avenues of spread. This principle is indicated even though lymph nodes may not be palpable in partial laryngectomy.
We present the follow-up and end results of 98 horizontal supraglottic laryngectomies done for treatment of supraglottic carcinomata. Both functional and oncologic outcome as well the complications and 5-year survival of these laryngectomies are considered. We conclude that this surgical technique is a suitable one for the larger part of supraglottic carcinomas.
Pathologic characteristic of supraglottic carcinoma spreading anterosuperiorly in 100 cases was investigated by whole-organ sections of the larynx. The results showed that 75% of supraglottic carcinomas were found to spread anterosuperiorly. In these cases, carcinoma in the epiglottis-ventricular fold accounted for 90%; epiglottic carcinoma 81.8%; and carcinoma in the ventricular fold 33.3%. Carcinoma in the aryepiglottic fold and arytenoid region was not noted to spread anterosuperiorly. In the cases with anterosuperior spreading of supraglottic carcinoma, the pre-epiglottic space was most commonly involved, which accounted for 60% of the cases; while the lingual surface of the epiglottis 42%; the vallecula 17%; the base of the tongue 12%; and the anterosuperior part of the thyroid cartilage 7%.
Supraglottitis is a rapidly progressive, life-threatening airway emergency in pediatric patients typically caused by Haemophilus influenzae type B (HIB). With distribution of the first efficacious vaccine for HIB in April 1985, changing disease patterns have begun to emerge; however, certain characteristics have remarkably persisted. The authors reviewed 252 pediatric patients with acute supraglottitis spanning the prevaccination and postvaccination years 1980 to 1992 at three major regional pediatric hospitals in Massachusetts, Ohio, and California, as well as at two community hospitals in Massachusetts. Findings include a decline in disease prevalence in all geographic areas with demographic, etiologic, and management evolution all seen. Children who had been immunized yet developed supraglottitis have been examined as predictive of future trends.
Conservative surgical treatment of carcinomas limited to the supraglottic larynx has been shown to be an oncologically and functionally effective therapeutic approach. A retrospective study was made of the medical records of 792 patients who underwent conservative surgery for supraglottic laryngeal carcinoma at the Gregorio Marañón University Hospital of Madrid, Spain, in 1962-1991. Our theoretical protocol for treating supraglottic tumors is presented. The oncological results (survival, local control, recurrences) and functional results (breathing, swallowing, voice quality) were analyzed.
Surgical management of early supraglottic cancer has evolved over the last half of the century from total laryngectomy to inclusion of conservation approaches. The development and fundamental principles underlying open supraglottic laryngectomy and endoscopic supraglottic resections are reviewed. In doing so, a rational approach for the application of these surgical techniques is provided for management of both the primary site and the neck.
It is widely accepted that tumor invasion and metastasis are the primary causes for the lethal clinical outcome of cancers. In recent years, attention has been drawn to PCNA (Proliferating Cell Nuclear Antigen) to predict the prognosis of some cancers. In the present paper, we have studied anti-PCNA antibody PC10 in supraglottic cancer by means of immunohistochemistry using paraffin-embedded sections, to demonstrate its clinical significance in this type of malignancy. Twenty-two patients with supraglottic cancer, including T1 (5 cases), T2 (13 cases) and T4 (4 cases) with N- (14 cases) and N+ (8 cases), were investigated for the PCNA expression. The percentages of PCNA positive cells were divided into three groups: < 25%, 25-75%, > 75%, with the range from 10.6 to 95.2%. Results showed that PCNA was well correlated with lymph node metastasis, and appeared to have an inverse correlation with histopathological grades. In this small group, we did not find that PCNA was correlated with T stages and tumor size. However, compared with other T-stages and tumor sizes, the correlation between lymph node metastasis and PCNA seemed to have more clinical significance in T2-stage and in tumors larger than 2 cm. PCNA could be used as a marker in predicting the clinical outcome in supraglottic cancers. An analysis on a large scale is anticipated.
BACKGROUND: Supraglottic hemilaryngopharyngectomy is a functional procedure suitable for the treatment of carcinoma of the upper part of the pyriform sinus and carcinoma of the lateral laryngeal margin. It consists of resection of the supraglottic hemilarynx and ipsilateral pyriform sinus. METHODS: Forty-nine patients underwent this procedure from 1979 through 1994. The median age was 51 (40-72). The data were collected by a review of patients' records. RESULTS: Two patients died in the postoperative period. The average time of removal of the nasogastric tube was 14 days. The survival rate at 3 years was 52% and at 5 years, 47%. The local recurrence rate was 2%, the overall neck recurrence was 15%, metastasis occurred in 15% of cases. CONCLUSIONS: Indications for this procedure are carcinoma of the upper part of the pyriform sinus and carcinoma of the laryngeal margin with normal vocal cord mobility.
PURPOSE: Pretreatment CT volumetric measurement of the primary tumor has been shown to be a predictor of local control in patients with laryngeal carcinoma treated with radiation therapy (RT) alone. A direct association has been demonstrated between tumor volume of supraglottic squamous cell carcinoma (SGSCCA) and local control. However, the association between tumor volume of SGSCCA and local control has not been investigated in patients treated surgically. The purpose of this study was to determine the relationship between SGSCCA tumor volume and local control in patients treated surgically. MATERIALS AND METHODS: Primary site tumor volume was calculated from pretreatment CT studies in 37 laryngeal supraglottic carcinomas treated surgically. All patients had clinical follow-up for evidence of recurrent tumor along the surgical margins at the primary site for a minimum of 2 years after completion of treatment. Statistical analysis consisted of Mantel-Haenszel chi-square tests and Fisher's exact test. RESULTS: Overall local control rate was 92% (33 of 37). Tumor volume was significantly associated with local control (p <. 05). Local control rate for tumors with volumes <16 cc was 94% (32 of 34) (p <.05). CONCLUSIONS: Pretreatment CT volumetric analysis is useful for predicting local control in patients with SGSCCA carcinoma treated surgically.
We reviewed the records of 104 patients with Stage T1NO or Stage T2NO epidermoid carcinoma of the supraglottic larynx treated between 1965 and 1979. In 79 patients, surgery was the only type of initial treatment. These 79 patients are the subjects of this report. Forty-eight (61%) of these patients were treated by total laryngectomy, whereas 31 (39%) had a partial laryngectomy. An elective unilateral radical neck dissection was performed on 31 patients considered at high risk, but metastatic disease was found in the dissected side of the neck histologically in only 32% (ten of 31) of these patients. The minimum follow-up period was 5 years and the maximum was 20 years. Twenty-nine percent of the patients (23 of 79) experienced a neck relapse. The neck relapse rate was the same whether the patients did or did not have an elective radical neck dissection. Among the patients who experienced a neck relapse, 65% (15 of 32) have died of the cancer. Among those who did not experience a neck relapse, none (zero of 56) have died of the cancer (P less than 0.01). These results indicate that in surgically treated patients with early stage supraglottic larynx cancer, neck relapse was the major cause of failure associated with death from cancer. Strategies for decreasing the relapse rate are discussed.
BACKGROUND: Prior studies have determined that macroscopic ("gross") tumor volume (GTV), as calculated from pretreatment computer tomography (CT), was capable of predicting local control in squamous cell carcinoma arising in different subsites in the head and neck in patients who were treated with nonsurgical organ-preservation therapy. The majority of these studies were single-institution, retrospective investigations. Consequently, there has been concern that GTV measurements may not be reproducible by different readers at different institutions. The objective of the current study was to measure the interobserver reliability for GTV measurements for squamous cell carcinoma of the supraglottic larynx (SGSCCA) performed by different readers at different institutions. METHODS: Eight experienced readers (4 neuroradiologists and 4 radiation oncologists) from different institutions independently measured the pretreatment GTV of 20 patients with SGSCCA. The CT scans were obtained from patients entered into the definitive radiation therapy arm of Radiation Therapy Oncology Group protocol 91-11, who had supraglottic carcinoma and underwent pretreatment CT scans of the neck. Statistical analysis focused on interobserver reliability as measured by the intraclass correlation coefficient. RESULTS: The intraclass correlation coefficient was 0.81 (95% lower confidence bound, 0.71). This value was interpreted as "excellent." CONCLUSIONS: GTV measurements were reliable and reproducible when performed by neuroradiologists and radiation oncologists who were experienced in the interpretation of CT scans of the extracranial head and neck in patients with SGSCCA. The result implied that the correlation between GTV and local control should be reproducible across institutions.
BACKGROUND: Paragangliomas of the larynx are unusual tumors that are seen as a vascular submucosal mass. These usually are seen in the supraglottic larynx but have also been found in the subglottis. This is the only laryngeal neuroendocrine tumor with a female predilection. It is important that paragangliomas be differentiated from other neuroendocrine tumors of the larynx, including atypical carcinoid, because of differing treatment modalities. METHODS: We present the clinical, radiologic, and pathologic findings of a supraglottic laryngeal paraganglioma seen in a 50-year-old woman with a 6-month history of slowly progressive hoarseness. RESULTS: The tumor was successfully approached by means of a midline laryngofissure with mucosal preservation. The patient remains disease free 24 months after surgery. CONCLUSIONS: Preoperative CT and angiography are useful in making the diagnosis of paraganglioma before surgical intervention. Complete excision through an external mucosa-sparing approach is the treatment of choice. Distinguishing laryngeal paraganglioma from other neuroendocrine tumors can be difficult. Immunohistochemistry is an important tool for the correct pathologic diagnosis.
BACKGROUND: We evaluated the functional and oncologic results of supraglottic hemipharyngolaryngectomy as treatment for T1 and T2 lateral laryngeal margin and piriform sinus carcinomas. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
An analysis of 129 patients with 131 squamous cell carcinomas of the supraglottic larynx treated between October 1964 and April 1987 with radiotherapy alone or radiotherapy followed by neck dissection is presented. All patients had a minimum 2-year follow-up. Patients were excluded from analysis of disease control at the primary site and/or neck if they died within 2 years of treatment with the site(s) continuously disease-free. Local control rates with radiotherapy and ultimate local control rates, including patients successfully salvaged after a local recurrence, were as follows: T1, 13 of 13 and 13 of 13; T2, 34 of 42 (81%) and 37 of 42 (88%); T3, 25 of 41 (61%) and 34 of 41 (83%); and T4, 3 of 9 and 6 of 9. There was no significant difference in local control rates when comparing patients who were anatomically suitable for a supraglottic laryngectomy with those who would have required a total laryngectomy. Local control rates were slightly diminished in patients with T2-T3 lesions who had impaired or absent vocal cord mobility. The overall rates of ultimate local control with voice preservation for the entire series of 129 patients were as follows: T1, 100%; T2, 87%; T3, 69%; and T4, 57%. Cause-specific survival rates at 5 years by stage were I, 2 of 2; II, 10 of 12 (83%); III, 9 of 13 (69%); IVA, 4 of 6; and IVB, 7 of 22 (32%). The incidence of severe complications was 4 of 115 (3%) for T1-T3 lesions and 4 of 14 (29%) for T4 lesions.