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Histoplasmosis of the larynx.

Histoplasmosis commonly infects the lower respiratory tract, causing either a sub-clinical or a nonspecific pulmonary illness. It may also affect the larynx from wide-spread dissemination or in a localized form that mimics carcinoma. Hoarseness, dysphagia, and pain on swallowing are symptoms common to many diseases of the laryngopharynx, including histoplasmosis. It is therefore important to consider this fungus in the differential diagnosis. Since culture techniques alone may not establish the diagnosis, special stains of tissue preparations and serologic tests for histoplasmosis are important adjuncts. We have recently seen and treated two cases of laryngeal histoplasmosis. Amphotericin B remains the preferred drug.

Adolescent↗

Infectious croup: a critical review.

Infectious croup is a viral or bacterial syndrome characterized by a barking cough, hoarseness, and stridor. Three separate conditions will be discussed: laryngotracheobronchitis, spasmotic croup, and bacterial tracheitis. Each clinical entity will be defined and its treatment reviewed. Current treatment regimens for infectious croup involve various combinations of mist therapy, racemic epinephrine, corticosteroids, and syrup of ipecac. Tradition, rather than science, appears to be the basis of many of these treatments. Despite the frequent occurrence of infectious croup, no treatment has proved consistently successful. Prevention and better treatment methods are the keys for reducing the high cost of infectious croup to the medical care system.

Bronchitis↗

Carcinoid tumor of the larynx: case report and review of the world literature.

The clinical, light microscopic, and ultrastructural features of a carcinoid tumor occurring in the larynx of an 80-year-old man are presented and compared with 22 laryngeal carcinoids described in the world literature. These 23 tumors occurred in persons from 45 to 80 years of age (mean age was 61 years) and were three times more common in men than in women. Hoarseness was the most common presenting symptom. Sixty-one percent of the tumors were supraglottic, 26% were transglottic, 4% were glottic, 4% were subglottic, and 4% were unspecified. At least 15 (65%) of the patients are known to have developed metastases. Nine of these (60%) presented with only regional lymph node metastases, one of which was occult. Surgery is the treatment of choice, with the extent dependent on the stage of disease. Radiation therapy appears ineffective, and chemotherapy is largely untested. The 2- and 4-year determinate survival rates were 59% and 25%, respectively.

Aged↗

The endoscopic management of early squamous carcinoma of the vocal cord with the carbon dioxide surgical laser: clinical experience and a proposed subclassification.

Sixteen patients with T1 vocal cord squamous cell carcinoma were treated with endoscopic laser excision during a 4-year period. Laser excision was the initial treatment in 11 patients, and it was used to treat 5 patients who had recurrence after radiotherapy. Postoperatively, 13 (81%) of the 16 patients had normal voices. Two patients with persistent postoperative hoarseness had had anterior commissure lesions and previous radiotherapy; the other patient had a subtotal cordectomy. One patient developed a subsequent new lesion 27 months after the initial laser treatment; he was successfully managed with a second endoscopic laser excision. Involvement of the anterior commissure or involvement of the vocal process with minimally invasive disease proved not to be a contraindication to laser excision. The overall results in this small series suggest that laser excision of T1 vocal cord carcinoma is an excellent method of treatment.

Adult↗

Phonatory volume velocity recording by use of hot film anemometry and signal analysis.

Phonatory airflow volume velocity signal was recorded from nine normal adult males and eight hoarse patients with laryngeal carcinoma; hot film anemometry and computer-aided signal analysis were used. Marked differences in phonatory flow signal were seen in the two groups. The normal phonatory flow signal is quasiperiodic, with excellent cycle-to-cycle repetition at the frequency of vocal fold vibration. The signal's spectral energy is dominated by the fundamental and its harmonics. The phonatory flow signal in cancer is characterized by random and aperiodic fluctuations. There is decreased AC-to-DC signal ratio. The phonatory signal spectra reveal little harmonic power. The loss of periodic flow signal is consistent with clinical observation of aperiodic vocal fold vibration in cancer. The analysis of airflow signal is a potentially valuable method for monitoring airflow during phonation in conditions affecting the larynx.

Adult↗

Laryngeal amyloidosis: a clinicopathologic and immunohistochemical review.

The clinical nature of laryngeal amyloidosis has not been well established, and the natural history of the disease remains a controversial matter. To address these issues, we reviewed the clinicopathologic and immunohistochemical features of 22 cases (11 men and 11 women; mean age, 56 years) of laryngeal amyloidosis. Hoarseness was the most common symptom, and the most frequent site affected was the false vocal cords. Six patients had concomitant tracheal amyloidosis. Paraffin blocks were available for immunostaining in 20 cases. Nineteen cases were positive for amyloid P component. lambda-Light chains were detected in 12 cases and kappa-light chains in 5; three cases did not show definite light-chain staining. Ten patients underwent repeated operations for persistent or recurrent respiratory tract disease. One patient died of progressive tracheobronchial amyloidosis, but systemic amyloidosis did not develop in any of the patients. Laryngeal amyloidosis is a form of localized amyloidosis characterized by monoclonal light-chain deposition. Recurrent respiratory tract disease is not uncommon, but the usual clinical course is relatively benign.

Adult↗

Combined valve operations with transection of ascending aorta.

To facilitate combined aortic and mitral valve operations, a new approach was developed. It was employed in 50 patients with both aortic and mitral valve disease. The ascending aorta was transected 1.5 cm above the aortic annulus, and the roof of the left atrium was incised. The damaged valves were replaced or repaired. Both aortic and mitral valves could be exposed satisfactorily by this approach. All patients recovered smoothly after the operation. Complications comprised intraoperative bleeding from the distal end of the ascending aorta in 1 patient and hoarseness in 3 postoperatively. The approach was considered quick and easy for combined valve operations.

Adult↗

Lethal midline granuloma starting as granuloma laryngis.

We report a case of lethal midline granuloma in a 34-year-old male patient. The patient was referred to our hospital because of long-lasting hoarseness. He was treated for granuloma laryngis. After two years nasal obstruction developed followed by ulceration of the hard palate and destruction of part of the nose and the upper lip. A biopsy demonstrated polymorphic infiltrate consisting of small lymphocytes, plasma cells, macrophages, atypical lymphoid cells and eosinophils. Radiotherapy was very effective and led to long-term remission. The different etiological aspects of this syndrome are discussed.

Adult↗

Cricoid chondrosarcoma coexisting with a thyroid mass: case report and review of the literature.

Laryngeal chondrosarcomas are rare cartilaginous tumors that usually present with hoarseness, dyspnea and, occasionally, dysphagia and dysphonia. We report the case of a low-grade chondrosarcoma of the cricoid cartilage coexisting with a right thyroid nodule, which presented with homolateral vocal fold paralysis. After a precautionary tracheotomy the patient underwent a laryngofissure in which the mass arising from the posterior plate of the cricoid cartilage was entirely enucleated. The histopathological analysis was compatible with a low-grade chondrosarcoma involving the posterior resection margin. For this reason, in agreement with the patient's wishes, a total laryngectomy and simultaneous right hemithyroidectomy were performed. We here discuss the peculiarity of the presentation and the therapeutic dilemma posed by this rare neoplasm.

Chondrosarcoma↗

Endobronchial metastasis of ovarian cancer. A case report.

An 83 years old woman with known ovarian carcinoma complained of dyspnea, dysphagia and hoarseness. Clinical and radiological investigations revealed a mediastinal metastasis involving and penetrating the right main bronchus. Palliation of dyspnea was achieved by laser therapy.

Adenocarcinoma, Papillary↗

Intubating laryngeal mask airway.

The Intubating Laryngeal Mask Airway (ILMA) was introduced into clinical practice in 1997 following numerous clinical trials involving 1110 patients. The success rate of blind intubation via the device after two attempts is 88% in "routine" cases. Successful intubation in a variety of difficult airway scenarios, including awake intubation, has been described, with the overall success rate in the 377 patients reported being approximately 98%. The use of the ILMA by the novice operator has also been investigated with conflicting reports as to its suitability for emergency intubation in this setting. Blind versus visualized intubation techniques have also been investigated. These techniques may provide some benefits in improved safety and success rates, although the evidence is not definitive. The use of a visualizing technique is recommended, especially whilst experience with intubation via the ILMA is being gained. The risk of oesophageal intubation is reported as 5% and one death has been described secondary to the complications of oesophageal perforation during blind intubation. Morbidity described with the use of the ILMA includes sore throat, hoarse voice and epiglottic oedema. Haemodynamic changes associated with intubation via the ILMA are of minimal clinical consequence. The ILMA is a valuable adjunct to the airway management armamentarium, especially in cases of difficult airway management. Success with the device is more likely if the head of the patient is maintained in the neutral position, when the operator has practised at least 20 previous insertions and when the accompanying lubricated armoured tube is used.

Anesthesia, Inhalation↗

Bilateral adductor vocal cord paresis following endotracheal intubation for general anaesthesia.

Recurrent laryngeal nerve palsy is a rare complication of endotracheal intubation. We report a case of bilateral vocal cord palsy following endotracheal intubation for general anaesthesia. The clinical picture was of hoarseness and aspiration suggestingpartialparesis, as complete bilateral recurrent laryngeal nerve palsy usually causes acute airway obstruction due to unopposed vocal cord adduction. Compression of the anterior branch of the recurrent laryngeal nerve between the cuff of the endotracheal tube and the posterior part of the thyroid cartilage was the likely mechanism. Ensuring that the cuff of the endotracheal tube is distal to the cricoid cartilage and that the pressure in the cuff is kept to the minimum required to prevent a gas leak should prevent this complication.

Adult↗

Vagus nerve stimulation treatment for Lennox-Gastaut syndrome.

Lennox-Gastaut syndrome is a severe age-specific epilepsy syndrome that presents with medication-resistant seizures in childhood. Antiepileptic drugs are the mainstay of treatment. Nonpharmacologic treatments include corpus callosum section and the ketogenic diet. However, no single treatment is safe and effective. We treated 13 patients with Lennox-Gastaut syndrome between the ages of 4 and 44 years (mean, 16.7 years) with vagus nerve stimulation. During the first 6 months of treatment, vagus nerve stimulation produced a median seizure rate reduction of 52% (range, 0% to 93%; P = .04). At 6 months of follow-up, three patients had a greater than 90% reduction in seizures, two had a greater than 75% reduction, one had a greater than 50% reduction, and six had at least a 25% reduction. One patient did not improve. No patient worsened after initial improvement. Side effects, including hoarseness, coughing, and pain in the throat, were transient and tolerable. No patient discontinued vagus nerve stimulation. Our results suggest that vagus nerve stimulation could be an effective and safe adjunct therapy for the treatment of Lennox-Gastaut syndrome.

Adolescent↗

A study to estimate the prevalence of upper respiratory tract papillomatosis in patients with genital warts.

Respiratory tract papillomas are associated with human papillomavirus (HPV) types 6 and 11; these HPV types are also commonly associated with genital warts (condyloma acuminata). Although most commonly seen in young children, the incidence of respiratory tract papillomas in young adults is increasing. It has been postulated that orogenital contact is the means of transmission in this age group. We performed a survey of adults with genital warts to assess the prevalence of respiratory tract papillomatosis in relation to sexual behaviour and other factors. Fifty-three adult patients (35 male, 18 female) with genital warts attending a genitourinary medicine clinic agreed to examination of the mouth and throat, including indirect laryngoscopy. Seventy per cent of the group had participated in oral sex. Two patients (3.8%) had lesions attributable to HPV infection of the oropharynx and larynx (one with laryngeal keratosis, one with papilloma of the pharynx). There was no specific risk factor identified to predict respiratory tract disease. In view of the high infectivity of genital warts, it is interesting to note the low prevalence of oropharyngeal warts in adults indulging in orogenital contact. Since malignant transformation is known in respiratory tract papillomas, we would recommend that any patient with genital warts who develops unexplained hoarseness has a specialist examination of the upper respiratory tract.

Adolescent↗

Agranulocytosis associated with sulfasalazine.

Agranulocytosis is a rare but potentially lethal adverse effect of sulfasalazine. We report a case of sulfasalazine-associated agranulocytosis that occurred in a 79-year-old woman who had been taking the drug for approximately seven weeks. The patient had discontinued the drug on her own initiative nine days prior to admission. The patient was admitted with complaints of hoarseness, fever, odynophagia, and malaise. The total white blood cell count was 600/mm3 with a differential of 0% neutrophils, 8% bands, 67% lymphocytes, and 25% monocytes; a bone marrow aspirate and biopsy revealed maturation arrest. The patient's peripheral white blood cell count and differential progressively increased over the nine-day hospital course. Upon discharge the white blood cell count was 12,000 cells/mm3 with 66% neutrophils, 8% bands, 16% lymphocytes, and 10% monocytes. Complete blood counts should be performed periodically in patients receiving sulfasalazine, especially during the first two months of therapy. Pharmacists should counsel patients to discontinue the drug and consult their physician immediately if they develop unexplained fever, chills, sore throat, malaise, or other nonspecific illness during the initial two months of treatment.

Aged↗

Osteoblastoma of the larynx: a case report.

We describe a unique case of an osteoblastoma in the cricoid cartilage of a 50-year-old man who presented with hoarseness and progressive dyspnea. Panendoscopic examination revealed a reddish tumor at the left side of the cricoid cartilage. Computed tomography (CT) imaging showed a sclerotic lesion involving the cricoid cartilage, protruding in the airway lumen. The tumor was removed via an external procedure. Histology confirmed the diagnosis of osteoblastoma.

Cricoid Cartilage↗

Aortoesophageal fistula secondary to mycotic thoracic aortic aneurysm: endovascular repair and transhiatal esophagectomy.

PURPOSE: To report a case of aortoesophageal fistula secondary to a mycotic thoracic aortic aneurysm (TAA) successfully repaired by stent-grafting of the descending thoracic aorta. CASE REPORT: A 66-year-old woman with a recent history of hemicolectomy for colon cancer complicated by postoperative infection presented with midthoracic pain, fever, hoarseness, and blood chemistries consistent with an inflammatory process. Imaging showed a widened mediastinum and displacement of the trachea due to a mycotic thoracic aneurysm; endoscopy confirmed a large fistula in the esophageal wall. There was no active bleeding, so an Excluder thoracic endograft was positioned in the aortic arch, partially covering the left subclavian artery origin. Three days later, a transhiatal esophagectomy was performed. Intravenous antibiotic therapy was continued for 6 weeks. At 18 months, a minithoracotomy was performed because of extreme dyspnea. An aneurysm sac hygroma was drained in the thoracic cavity. At 2 years, the patient was well, and there were no signs of infection or dyspnea. CONCLUSIONS: Along with a transhiatal esophagectomy, we suggest that endovascular stent-grafting has a place as a minimally invasive technique in the treatment of aortoesophageal fistula secondary to aneurysm of the thoracic aorta.

Aged↗

Mediastinal bronchial artery aneurysm treated with a stent-graft.

PURPOSE: To report a rare case of mediastinal bronchial artery aneurysm successfully treated with an endovascular stent-graft. CASE REPORT: A 79-year-old man with a history of tuberculosis was admitted to our hospital complaining of worsening hoarseness. Examination revealed a large mediastinal bronchial artery aneurysm located near the origin of the artery. Since neither surgical intervention nor transcatheter embolization was feasible, an endovascular stent-graft repair was performed using a newly developed stent-graft constructed from a nitinol stent and a thin membrane of polyester. Postprocedural angiography showed satisfactory exclusion of the aneurysm. The patient made an uneventful recovery. The 18-month computed tomographic scan documented continued exclusion of the aneurysm, with no evidence of endoleak, graft thrombosis, or migration. CONCLUSIONS: When conventional procedures are too complicated for bronchial artery aneurysms, endovascular stent-graft repair can be a useful approach.

Aged↗