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PubMed1989

Esophageal stethoscope. Another possible cause of vocal cord paralysis.

Hoarseness after endotracheal intubation can result from compression of the anterior branch of the recurrent laryngeal nerve as it passes behind the thyroid cartilage to innervate the lateral cricoarytenoid muscle. This usually occurs when the cuff of the endotracheal tube lies in the larynx instead of the trachea. When a nasogastric tube is positioned in the midline, resultant postcricoid inflammation can result in vocal cord immobility. This may result from neuropraxia of the posterior branch of the recurrent laryngeal nerve that innervates the posterior cricoarytenoid and interarytenoid muscles, or inflammatory spasm of the interarytenoid muscles themselves. We present a case of vocal cord paralysis after general anesthesia that may have been caused by an esophageal stethoscope. The mechanism for vocal cord immobility could be similar to that of a midline nasogastric tube with resultant postcricoid inflammation. We describe measures that can be taken to prevent vocal cord paralysis after intubation of the larynx or esophagus.

Adult↗
PubMed1990

Laryngeal pacing in unilateral vocal cord paralysis. An experimental study.

In an attempt to remobilize a unilaterally paralyzed vocal cord, experiments were made in five adult dogs. Adduction of the paralyzed vocal cord for phonation in synchrony with the intact cord was achieved by electrical stimulation of the adductor muscles that was triggered by the signals from the cricothyroid muscle. The difference in the level of action potentials of the cricothyroid muscle between during phonation and during respiration was used for setting the threshold so as to differentiate phonation from respiration. Nearly synchronous movement of the two vocal cords thereby attained during phonation greatly improved the voice quality that was hoarse without the paced stimulation.

Action Potentials↗
PubMed1991

Laryngeal involvement in disseminated coccidioidomycosis.

Coccidioidomycosis is a pulmonary fungal infection endemic to the desert southwest of the United States and northern Mexico. Rarely (0.5% of cases), the fungus disseminates widely, causing life-threatening complications. Seven percent of these cases will involve the head and neck. We report a case of disseminated coccidioidomycosis that involved the larynx and cervical lymph nodes in a 40-year-old white woman who presented with hoarseness and unsuspected airway compromise. Review of the 12 reported cases of laryngeal coccidioidomycosis showed a predominance of male and dark-skinned patients; seven were children, and nine presented with airway compromise. Other reported sites of head and neck involvement include the skin, mucosa, bones of the skull, and meninges, and there have been reports of abscesses of the soft tissues and fascial spaces of the neck.

Adult↗
PubMed1992

Laryngoceles and saccular cysts in infants and children.

Laryngoceles and saccular cysts are an unusual cause of respiratory obstruction in infants and children. Laryngoceles in particular are less common in the pediatric population than in adults. They typically produce intermittent upper airway obstruction and hoarseness (due to episodic filling with air), and are, therefore, difficult to diagnose. Saccular cysts produce similar symptoms but are not episodic. While smaller anterior saccular cysts are readily managed by endoscopic excision, larger saccular cysts tend to recur repeatedly. Review of experience with 20 infants and children having saccular pathologic changes (17 saccular cysts and three laryngoceles) suggests that saccular lesions are more troublesome than is generally appreciated. The clinical course is typically a lengthy one, with multiple endoscopic procedures. Most patients required tracheotomy, some under emergent conditions. Three patients acquired subglottic stenosis; one was clinically significant. A fourth patient had a congenital subglottic stenosis. Saccular cysts can be managed endoscopically in many cases, but if persistent after two or three endoscopic procedures, a prolonged course can be anticipated. Complete excision, endoscopically or through an external surgical approach, may shorten the clinical course.

Adolescent↗
PubMed1993

Mycosis fungoides involving the cervical esophagus.

Review of the otolaryngologic literature reveals no case reports of mycosis fungoides involving the esophagus. Post-mortem studies report 12 cases of esophageal involvement in 131 autopsies of patients with mycosis fungoides. We describe a 54-year-old man with mycosis fungoides involving the larynx, hypopharynx, and esophagus. Treatment consisted of radiation to this area, with resolution of the patient's hoarseness and dysphagia. The charts of 96 patients with mycosis fungoides treated at our institution were retrospectively reviewed. Three additional cases involving the aerodigestive tract, but not the esophagus, were found. Esophageal mycosis fungoides was an incidental finding in two of seven autopsies at our institution.

Esophageal Neoplasms↗
PubMed1995

Multifocal amyloidosis of the pediatric airway.

Amyloidosis of the upper aerodigestive tract is rare in the pediatric age group. We present the first reported case (to our knowledge) of multifocal primary upper airway amyloidosis in a child. An otherwise-healthy 15-year-old girl presented with hoarseness, nasal congestion, and odynophagia. Diagnostic evaluation included flexible nasopharyngoscopy, rigid nasal endoscopy, direct laryngoscopy, bronchoscopy, and biopsy. The results of Congo red staining of the specimen were characteristic of amyloid. The findings of an extensive immunologic and systemic evaluation were normal. We discuss the treatment and postoperative course of this patient, as well as the clinical and pathologic characteristics of amyloidosis, with particular reference to the otolaryngologic manifestations of amyloidosis.

Adolescent↗
PubMed1995

Laryngeal oncocytic cystadenomas. Eight cases and a literature review.

OBJECTIVE: To describe an uncommon clinical entity, laryngeal oncocytic salivary adenomas. BACKGROUND: While the nomenclature of these lesions may differ depending on their histologic appearance, these tumors are all generally part of a spectrum of clinically benign cystic and papillary lesions derived from oncocytic metaplasia and hyperplasia of minor salivary ducts. DESIGN: Eight cases of laryngeal oncocytic lesions collected from two institutions. Further clinical background and follow-up data were obtained on five of eight patients. RESULTS: Patients were mostly in their seventh and eighth decades of life, and all who were questioned had smoking histories. Hoarseness was a common presenting complaint, and all patients had polypoid laryngeal masses. One patient presented with progressive upper airway obstruction, which was ultimately fatal; the laryngeal oncocytic cystadenoma was diagnosed in this case during postmortem examination. The laryngeal lesions were predominantly supraglottic. Histologically, they consisted of oncocytic metaplasia of the minor salivary ducts, cystic dilation, and papillary and microcystic hyperplasia. No recurrences were seen in those patients with follow-up (four of eight). CONCLUSIONS: Laryngeal oncocytic lesions usually present as supraglottic masses in older patients. While they are oncologically benign and nonrecurring after endoscopic removal, they may occasionally be the cause of significant upper airway obstruction.

Aged↗
PubMed1983

Indications for flexible fiberoptic bronchoscopy in pediatric patients.

Although the availability of flexible fiberoptic bronchoscopy (FFB) has been a major advance in adult pulmonary medicine, the role of FFB in pediatrics has remained less well defined. Therefore, a two-year retrospective study was undertaken to determine the indications for FFB in 95 pediatric patients (mean age, 6.9 years) who underwent 129 FFB procedures. Indications for FFB included stridor (41/129), abnormal chest roentgenogram (38/129), airway evaluation in patients with tracheostomy (13/129), airway obstruction (11/129), hoarseness (9/129), recurrent pneumonia (7/129), chronic cough (4/129), failed extubation (3/129), tracheal injury (2/129), and hemoptysis (1/129). Overall, a specific diagnosis was made in 88% of cases, of which 48% involved a lower airway disorder. A minor complication rate of 2% was observed with no major complications.

Adolescent↗
PubMed1984

Motor disorders of voice and speech in Reye's syndrome survivors.

Disorders of voice and speech were studied in 43 survivors of Reye's syndrome (RS). During hospital convalescence 26 (60%) of 43 were aphonic, hoarse, or had other alterations of speech production. These disorders occurred in those patients with the worst severity of RS. Four patients (9% of survivors) had a persistent motor voice or speech disorder at follow-up examination 1 1/2 to five years after recovery. All of the patients have breathy, low-intensity voice quality, whereas three of the four exhibit rapid and slurred speech. These four children have no difficulty with the symbolic aspects of language and their motor voice and speech impairment cannot be ascribed to global intellectual deficit. Although other neurologic deficits are present in three of these four children, the disorders of voice and speech are the major permanent disabling handicap in our RS survivors.

Adolescent↗
PubMed1988

Safety and efficacy of flexible endoscopy in children with bronchopulmonary dysplasia.

Because concern has been raised about the efficacy and safety of flexible fiberoptic bronchoscopy (FFB) in pediatric patients with chronic cardiopulmonary disorders, we reviewed the results of 129 flexible endoscopies performed on 47 children with a history of bronchopulmonary dysplasia (BPD) at our institution over a 44-month period. Indications for FFB; weight and age of the patient; and procedure format, including medication usage, findings, specimen results, and complications, were analyzed. Evaluation of previously diagnosed subglottic stenosis and airway abnormalities were the two most common indications (33% and 32%, respectively). Persistent or recurrent infiltrates or atelectasis, need for cultures, stridor, failure to extubate, hoarseness, and persistent wheeze were also cited. Endoscopic diagnoses included adenoidal hypertrophy, laryngomalacia, vocal cord abnormalities, interarytenoid membrane, subglottic stenosis, granulomas, tracheobronchomalacia, stenosis, obstruction, generalized inflammation/edema, polyps, tracheal bronchi, and anomalous bronchial anatomy. Cytomegalovirus, pneumococcus, nontypeable Haemophilus influenzae, Pseudomonas, or mixed gram-negative flora were isolated from some patients without tracheostomy. Minor complications (transient bradycardia, mild nasopharyngeal bleeding, and mild worsening of upper airway obstruction) occurred in 3.1% of procedures, but no severe complications occurred. Management was directly affected by procedure results in 41% of procedures. We concluded that the FFB can be a safe, useful procedure in the management of children with BPD.

Bronchial Diseases↗
PubMed1993

Acquired subglottic cysts in the low-birth-weight infant. Characteristics, treatment, and outcome.

OBJECTIVE: To provide a descriptive summary of characteristics, including demographics, symptoms, risk factors, and outcome of acquired subglottic cysts identified in the neonatal period. DESIGN: Patient series. SETTING: A tertiary neonatal care unit and referral neonatal follow-up clinic. PARTICIPANTS: One hundred seventy-four preterm infants undergoing flexible bronchoscopy, 21 (12%) referred for airway evaluation because of symptoms and 153 (88%) examined consecutively following 7 days or more of endotracheal intubation. INTERVENTION: None. MEASUREMENTS/RESULTS: Subglottic cysts were identified in 11 (7.2%) of 153 preterm infants examined prospectively at discharge from the neonatal intensive care unit after prolonged intubation and two (10%) of 21 infants referred for airway evaluation. Infants with subglottic cysts were extremely preterm (mean +/- SEM gestation, 26.7 +/- 0.5 weeks) and very low birth weight (894.6 +/- 64.6 g). The mean duration of intubation was 28.5 +/- 5.0 days. Most infants, particularly those with large cysts, were symptomatic with stridor, hoarseness, or obstructive apnea. In two cases, airway symptoms began after discharge from the neonatal intensive care unit. Ten (91%) of the 11 patients were discharged receiving home oxygen. Generally, multiple cysts were present in the subglottic space, most prominently located in the posterior aspect of the trachea. Three of five patients with large cysts received a tracheostomy. Two additional patients had surgical marsupialization of the cysts, and six others experienced resolution without treatment. One patient with large cysts died of viral pneumonia 10 months after surgical intervention. An additional patient with large cysts died before surgical intervention secondary to chronic lung disease and cor pulmonale. All surviving infants had resolution of signs of airway obstruction and 10 of the 11 did not require supplemental oxygen or have symptoms of chronic pulmonary disease at age 1 year. CONCLUSION: Intubation-acquired subglottic mucous cysts in the neonate may occur more commonly than was previously recognized. Symptoms of this lesion may mimic features of chronic lung disease. Early identification of the cysts with flexible bronchoscopy is important since airway compromise may progress and surgical intervention may be lifesaving.

Bronchoscopy↗
PubMed2000

The necessity for a thoracic approach in thyroid surgery.

HYPOTHESIS: A thoracic approach is commonly required in certain subsets of patients with a mediastinal thyroid mass. DESIGN: A retrospective review. SETTING: A tertiary referral center. PATIENTS: Nine hundred seventy-six consecutive patients who underwent thyroid surgery by a single surgeon from June 1, 1991, to March 30, 1999. Symptoms of airway compression, including respiratory distress, dyspnea, hoarseness, dysphagia, and persistent cough, were the most common presenting symptoms. The patients ranged in age from 27 to 89 years (mean, 63 years). RESULTS: Patients in whom the computed tomographic scan and operative findings revealed that at least 50% of the thyroid mass was below the thoracic inlet were considered to have a mediastinal mass. These strict criteria identified 94 patients with a mediastinal thyroid mass. Twenty-seven (29%) of these patients required a thoracic approach. The thoracic approach consisted of 21 partial sternotomies, 5 full sternotomies, and 1 right posterolateral thoracotomy. Fifteen patients had a malignant neoplasm. Fourteen patients had a papillary carcinoma, and 3 of these patients had a multifocal microscopic papillary carcinoma within a multinodular colloid goiter. One patient had a follicular carcinoma. Seven patients underwent reoperative surgery, 5 for a malignant tumor and 2 for a benign tumor. Five patients had a posterior tumor, and 2 had an aberrant mediastinal thyroid mass. Twenty-two (81%) of the 27 patients who underwent a thoracic approach fell into one of the following categories: malignant neoplasm, reoperation, or aberrant or posterior mediastinal thyroid mass. CONCLUSIONS: Subsets of patients with a mediastinal thyroid mass are at considerably increased risk for requiring a thoracic surgical approach. These subsets include patients with malignant mediastinal tumors, patients undergoing reoperative thyroid surgery, and patients with posterior or aberrant mediastinal thyroid masses. Surgeons should be prepared for the increased likelihood of a thoracic approach in these subsets of patients.

Adult↗
PubMed2004

Predictors of airway complications after thyroidectomy for substernal goiter.

HYPOTHESIS: Airway complications after thyroidectomy for substernal goiter can be predicted by preoperative symptom profiles, radiologic findings, or other factors. DESIGN: Retrospective review. Settings A university tertiary care center and a veterans' hospital. PATIENTS: Sixty patients with substernal goiter who underwent thyroidectomy between 1993 and 2002. MAIN OUTCOME MEASURES: Symptoms, preoperative radiologic findings, extent of thyroid resection, tumor size, and postoperative complications. RESULTS: Dysphagia was the most common preoperative symptom (n = 26), followed by dyspnea (n = 21), orthopnea (n = 13), and hoarseness (n = 6); 18 patients (30%) had superior vena caval obstruction. Thirteen patients (22%) were asymptomatic. Preoperative imaging identified tracheal deviation or compression in 45 patients (75%). Substernal goiter was resected via a cervical approach in 59 patients (98%). Of 47 patients with preoperative symptoms, 41 (87%) reported improvement postoperatively. Seven patients (12%) had postoperative airway complications: 1 developed a neck hematoma requiring reoperation, and 6 could not be immediately extubated; all 6 were successfully extubated after 1 to 10 days. Patients with airway complications were older (mean +/- SEM, 70.3 +/- 3.6 years vs 61.5 +/- 2.2 years), had larger goiters (mean +/- SEM, 210.7 +/- 37.0 g vs 112.2 +/- 7.7 g), and were more likely to have tracheal compression on preoperative imaging than those who did not have complications (P<.05). CONCLUSIONS: Most patients with substernal goiters underwent thyroid resection via a cervical approach with an improvement in symptoms. The few patients who developed postoperative airway complications were older, had larger goiters, and were more likely to have tracheal compression on preoperative imaging than those without airway complications.

Age Factors↗
PubMed2006

Increased mortality and morbidity associated with thyroidectomy for intrathoracic goiters reaching the carina tracheae.

HYPOTHESIS: Complications associated with thyroidectomy for intrathoracic goiters have been underestimated because of the lack of a precise definition of high-risk patients. DESIGN: Retrospective multicenter multinational review of medical records and radiographic images of patients who underwent thyroidectomy for intrathoracic goiters reaching the carina tracheae. Demographic, clinical, operative, anatomical, and pathological data were recorded. RESULTS: There were 35 patients (mean +/- SE age, 63 +/- 11 years) included in the study. In 4 patients, the goiter was asymptomatic; 10 patients had dysphagia, 24 patients had dyspnea, and 3 patients had superior vena cava syndrome. A median sternotomy was required in 12 patients and a right-sided thoracotomy in 1 patient. The mean +/- SE operative time was 145 +/- 72 minutes (range, 50-360 minutes). Transient hypoparathyroidism developed in 13 patients. Four patients experienced transient hoarseness, and 1 patient had permanent vocal cord paralysis. There were no significant differences between the proportion of patients who underwent or did not undergo sternotomy or thoracotomy regarding vocal cord dysfunction (2 [15%] of 13 patients vs 3 [13%] of 22 patients) or hypoparathyroidism (5 [38%] of 13 vs 6 [28%] of 22 patients). The mean postoperative hospital stay was 10 days (range, 2-84 days). Four patients required reoperation. Two patients died. Nine of 14 patients with thyroid glands weighing at least 260 g required sternotomy vs 3 of 14 patients with thyroid glands weighing less than 260 g (P = .02). Overall, 18 [52%] of 35 patients were discharged without any complication. CONCLUSION: Intrathoracic goiters reaching the carina tracheae carry a high unreported risk of sternotomy, postoperative complications, reoperation, and death.

Adult↗
PubMed1976

Bilateral vocal cord paralysis. A complication of percutaneous cannulation of the internal jugular veins.

A severe complication resulted from internal jugular cannulation. An obese patient had hematomas after bilateral attempts. The first cannulation (on the right) was successful after many tries; the second (on the left) was not. The patient was hoarse after the first attempt; more so and dyspneic after the second. Laryngoscopic examination showed paralysis of the vocal cords. Tracheostomy was done. Two weeks later, the cords were seen to move normally. The tracheostomy was removed, and recovery was uneventful.

Catheterization↗
PubMed1998

Zinc gluconate lozenges for treating the common cold in children: a randomized controlled trial.

CONTEXT: The common cold is one of the most frequently occurring illnesses and is responsible for substantial morbidity and economic loss. Biochemical evidence suggests that zinc may be an effective treatment, and zinc gluconate glycine (ZGG) lozenges have been shown to reduce the duration of cold symptoms in adults. OBJECTIVE: To determine the efficacy of ZGG treatment of colds in children and adolescents. DESIGN: A randomized, double-masked, placebo-controlled study. SETTING: Two suburban school districts in Cleveland, Ohio. PATIENTS: A total of 249 students in grades 1 through 12 were enrolled within the first 24 hours of experiencing at least 2 of 9 symptoms of the common cold. INTERVENTION: Zinc lozenges, 10 mg, orally dissolved, 5 times a day (in grades 1-6) or 6 times a day (in grades 7-12). MAIN OUTCOME MEASURES: Time to resolution of cold symptoms based on subjective daily symptom scores for cough, headache, hoarseness, muscle ache, nasal congestion, nasal drainage, scratchy throat, sore throat, and sneezing. RESULTS: Time to resolution of all cold symptoms did not differ significantly between students receiving zinc (n = 124) and those receiving placebo (n = 125) (median, 9 days; 95% confidence interval [CI], 8-9 days; median, 9 days, 95% CI, 7-10 days, respectively; P=.71). There were no significant differences in the time to resolution of any of the 9 symptoms studied. Compared with controls, more students in the zinc group reported adverse effects (88.6% vs 79.8%; P=.06); bad taste (60.2% vs 37.9%; P=.001); nausea (29.3% vs 16.1%; P=.01); mouth, tongue, or throat discomfort (36.6% vs 24.2%; P=.03); and diarrhea (10.6% vs 4.0%; P=.05). CONCLUSIONS: In this community-based, randomized controlled trial, ZGG lozenges were not effective in treating cold symptoms in children and adolescents. Further studies with virologic testing are needed to clarify what role, if any, zinc may play in treating cold symptoms.

Adolescent↗
PubMed1998

Behavioral phenotype of Smith-Magenis syndrome (del 17p11.2).

Smith-Magenis syndrome (SMS) is a distinct and clinically recognizable multiple congenital anomaly (MCA) and mental retardation syndrome caused by an interstitial deletion of chromosome 17 p11.2. The phenotype of SMS has been well described and includes: a characteristic pattern of physical features; a hoarse, deep voice; speech delay with or without associated hearing loss; signs of peripheral neuropathy; variable levels of mental retardation; and neurobehavioral problems. Although self-injury and sleep disturbance are major problems in SMS, studies are limited on the behavioral phenotype of SMS. This report reviews the current state of knowledge about SMS and presents new data based on syndrome-specific observations by the authors' longitudinal experience working with SMS, specifically related to the behavioral aspects of SMS. This information should have relevance for parents, clinicians, geneticists, and educators involved in the care of individuals with SMS.

Abnormalities, Multiple↗
PubMed1999

Costello syndrome: report and review.

We describe a 34-year-old woman with mental retardation, short stature, macrocephaly, a "coarse" face, hoarse voice, and redundant skin with deep palmar and plantar creases who had evident Costello syndrome. Lacking papillomata, she had wart-like lesions of the skin. The previously reported patients with Costello syndrome are reviewed. Costello syndrome is probably an autosomal dominant disorder, either caused by a mutation in a single gene or by microdeletion.

Abnormalities, Multiple↗