Annals of Otology,Rhinology & Laryngology

The life cycles of the tumor virus SV40 and polyoma are discussed with particular emphasis on the role of the viral coded proteins which mediate the transformation of normal cells into their cancerous equivalents. One or more of these proteins possibly act by stimulating directly the synthesis of cellular DNA, while others may mimic the action of polypeptide mitogens that act at the cell surface.

One hundred and forty cases of papilloma of the larynx and tracheobronchial tree are documented in the records of the Childrens Hospital of Los Angeles. The records of 90 patients were available and were reviewed intensively. The method of direct laryngoscopy with general anesthesia using apneic technique in most patients and intubation in some was an adequate method of treating patients with laryngeal papillomata. A general anesthetic was never used where obstruction was severe and the airway could not be controlled. The low incidence of papilloma of the tracheobronchial tree and an absence of parenchymal lung seeding in this series is attributed to the avoidance of a tracheotomy and fewer intubation anesthetics thus avoiding trauma to the trachea and bronchi. The immediate removal of the tracheotomy tube seems an alternative if the surgical procedure had been performed. In the patients in this series decannulation was accomplished in a very short period of time. The establishment of an airway seems to be a priority in the treatment of this disease and this can be accomplished by repeated endoscopic procedures rather than tracheotomy. Statistics are given, and prognosis based on the type of lesion and histopathology is documented.

A two-year-old female presented to the author with a 1½ year history of multiple recurrences of juvenile laryngeal papillomatosis which when first seen had progressed to and below the tracheotomy site. The entire supraglottic larynx, glottis, and subglottic area were completely filled with exuberant papillomata. There was active growth of papilloma at and below the tracheotomy site and the tube had to be inserted through papilloma in order to reach a clear area in the trachea. In hopes of preventing further spread of papilloma below the area already involved and in order to control the airway and provide access to the subglottic area for laser removal, a double-barreled tracheostomy was performed. Laser treatment and/or spontaneous resolution ultimately resulted in complete clearing of all papillomata from the upper and lower tracheal segments. Four years and nine months after the initial procedure it was felt safe to attempt reconstruction. Her postoperative course was uneventful and she was successfully extubated three months later. Both vocal cords are normally mobile and her voice is quite clear although slightly hoarse as a result probably of slight changes in the edges of the cords because of the repeated surgical interventions. There has been no recurrence of papilloma now, over one year since reconstruction of the trachea. This somewhat radical approach to a life-threatening growth of endotracheal papilloma was successful in preventing further spread below the level of tracheostomy and ultimately permitted total reconstruction of an intact tracheal bronchial tree in the case reported.

Long-term endotracheal intubation is a widely established means of giving ventilatory support in the newborn period. Though such long-term intubation is well tolerated by the premature infant, laryngeal complications do occur and extubation may be impossible even though the initial disease process for which the intubation was performed has resolved. In such a situation, careful endoscopic evaluation of the upper respiratory tract is advocated to identify the site of the problem. If subglottic edema or mucosal ulceration in the subglottic area is the site of the damage and if, during endoscopic evaluation immediately following removal of the endotracheal tube, the subglottic area starts to narrow because of edema formation or edema fluid filling up compressed granulation tissue, then a split of the cricoid in the midline anteriorly, leaving the endotracheal tube in as a stent, appears to be a preferable alternative to performing a tracheotomy. Of 12 consecutive patients, 9 have been successfully extubated.

Thirty neonates with acquired airway stenosis were treated between 1975 and 1979 at the C. S. Mott Children's Hospital of the University of Michigan. Neonates surviving a period of ventilation are at risk of developing subglottic stenosis (8.3%). The stenosis is often severe. Children with respiratory distress syndrome and/or neurologic disorders were particularly prone to developing a stenosis (37 %). Following treatment, 43% were successfully decannulated and decannulation occurred in a biphasic pattern. Thirty-seven percent were still tracheostomy-dependent but had a voice and were developing normal speech patterns. The mean decannulation time was 92.5 weeks, confirming that acquired subglottic stenosis in the neonate is a serious problem with long-term disability.

The use of an inert stent as an adjunct to surgical procedures to correct laryngotracheal stenoses remains somewhat controversial. It is the purpose of this report to describe the use of long-term stents in seven patients with either acute or chronic laryngotracheal stenoses. The conclusion from this series is that stenting for prolonged periods of time represents a valuable adjunctive technique in the correction of the more severe airway reconstruction problems.

This presentation is to introduce a silicone tracheal cannula which has been designed for use in selected cases instead of a tracheotomy tube. The design of the cannula was developed in the laboratory and has now been used clinically over a period of four years in 26 cases. Special features of the cannula include a one-size diameter which is suitable for all adults. An inner flange is shaped so as to conform with the inner aspect of the anterior wall of the trachea and to prevent rotation and anterior displacement of the cannula. The inner flange is angulated to allow for proper direction of the long axis of the cannula. An outer flange fits into one of a number of grooves and prevents posterior displacement of the cannula. Thus far the silicone tracheal cannula has been used in cases of sleep apnea, bilateral vocal cord paralysis in the position of adduction, intermittent glottic insufficiency, laryngeal carcinoma, chronic lung disease, and short-term necessity for a tracheotomy. Special equipment has been designed for ease of the surgical procedure required for insertion of the cannula. A oneway valve has been designed which is easily applied to the cannula. A variation of the silicone tracheal cannula has been designed for long-term use.

Reports of restoration of voice after total laryngectomy include diversion of exhaled pulmonary air through planned or spontaneous fistulae with a variety of modified tracheal cannulas and valves. Limitations of these techniques include aspiration, scar closure of the shunts, wound complications, and failure to achieve voice consistently. We report a two-year experience with an endoscopic method using a unique valved prosthesis eliminating complicated surgical reconstructions, aspiration, and stenosis. Fifty-four of 60 patients (90%) achieved fluent voices with one deglutition problem. Radiation therapy preceded voice restoration in 63% of the patients and radical neck dissection in 72%. The endoscopic procedure, hospitalization and period of speech therapy are short and constitute a cost-effective voice rehabilitation program. The results of this simple method and lack of complications are encouraging.

The purpose of this paper is to analyze the problems and complications which have resulted from neoglottic reconstruction at the University of Texas Medical Branch in Galveston. It has been performed as a primary procedure at the time of laryngectomy on 50 patients. Over 40 % of these patients have required a second operative procedure to control major complications of their neoglottis. Aspiration is a nearly constant feature of the procedure, and a significant number of patients do not tolerate it well. Radiation therapy does not appear to increase the number of problems, but the complications are more severe when they do occur, and they are more difficult to control. The indications for surgical neoglottic reconstruction cannot be extended beyond those tumors which are within the confines of the larynx without an increased incidence of major complications. Other relative contraindications to this surgery are poor patient pulmonary reserve, reflux esophageal incompetence, and a “hyperactive” gag reflex. Nine patients with prior treatment which included a total laryngectomy underwent secondary neoglottic reconstruction. In our experience, all have had significant aspiration. About one half of these patients developed speech. The procedure of neoglottic reconstruction must be reviewed critically prior to popular introduction into the surgical armamentarium. A plea for careful study by a small number of experienced surgeons is now in order.

Numbers play a great role in our practice of laryngology, and when used appropriately can be extremely valuable. However, careless or uncritical use may cause them to be an impediment or detriment to clinical practice and teaching. Examples of problems which arise with numbers are readily found in the areas of tumor staging (TNM system), the scientific literature, resident training and communications with third-party agencies. Consideration of these examples reminds us of the need to evaluate our use of numbers frequently.

Vocal cord positioning produced by selective laryngeal denervation remains a controversial issue in clinical laryngology. Previous studies fail to arrive at uniform conclusions for two important reasons: 1) failure to mark a reference sagittal plane from which to assess the degree of vocal cord lateralization, and 2) failure to recognize the influence of tracheostomy and respiratory positioning of the vocal cords. The present study makes use of photographic and electromyographic documentation in the assessment of the paralyzed cord. Physiologic inactivation of the cricothyroid muscle by tracheostomy is a key determinant of the lateralized cord observed in acute low vagal and recurrent nerve paralysis. Tracheostomy-related cricothyroid inactivation cannot be ignored as a major determinant of cord positioning in paralysis and should not be overlooked in determining the neuroanatomic site of injury.

A simple and inexpensive method of laryngeal photography through the eyepiece of the operating microscope is described. Provided that the operating room is equipped with the microscope, the laryngoscope and the laryngoscope holder, the only essential equipment required is an “aperture-preferred” automatic single lens reflex camera with a 50 mm macrolens. The macrolens of the camera is placed against an eyepiece of the microscope and the laryngeal image is centered and focused via the viewfinder of the camera. The respiration of the patient is temporarily halted. The camera is held still and pictures taken. Kodak high speed Ektachrome® tungsten film ASA 160 is used and push-processed to ASA 320. With practice, one should be able to obtain satisfactory photograph of the larynx suitable for teaching and documentation.

A retrospective study was done of 602 patients with primary squamous cell carcinoma of the upper aerodigestive tract and a clinically negative neck (N _o ) seen at the University of Illinois Hospital between 1960–1975. There was no uniform policy as to the treatment of N _o neck during this period; therefore in many of the patients, cervical lymph nodes were treated with elective neck dissection and others were followed until they became positive clinically. It was this difference which formed the basis for this study. All the patients were treated surgically; the patients were placed into two groups depending on whether they had radical neck dissection at the same time as resection of the primary. Group 1 consisted of 149 patients and had surgery for the primary only. The 253 patients of group 2 had surgery for the primary and also had a neck dissection. Both groups were analyzed for recurrences in the cervical region. In group 1, 12.9 % of the patients developed either ipsilateral or contralateral metastases. Of the group 2 patients, 22% developed palpable nodal disease. The evolution of palpable nodal disease was analyzed by primary site, T-stage, and according to whether the tumor at the primary was controlled. Only 3% of the patients developed lymph nodes when the primary was controlled. The pathology reports of the neck specimens were studied to determine the relationship between a) positive node histology and b) number of nodes positive to the recurrence rate in the neck Our results showed a 23% failure rate for the histologically positive group and a 21% failure rate for the negative group. The number of positive nodes did not seem to affect the recurrence rate.

This report details the diagnosis and treatment of a patient with a large T₃ N₀M₀ laryngopharyngeal cancer by combined surgical excision and planned postoperative irradiation therapy. Surgical excision included a horizontal subtotal supraglottic laryngectomy combined with a vertical hemilaryngectomy and partial pharyngectomy. The patient was reconstructed with a free sternocleidomastoid muscle graft. The results and implications of this therapy are discussed.

Acute cricoarytenoid arthritis is a frequent complication of rheumatoid arthritis and the most frequent otolaryngologic manifestation of the disease. Over 25% of rheumatoid arthritis cases have discomfort from this problem. Other etiologies can produce cricoarytenoid arthritis. Symptoms range from mild discomfort through hoarseness to complete airway obstruction requiring emergency tracheotomy. Chronic cricoarytenoid arthritis may result in joint ankylosis and vocal fold fixation. Single periarticular triamcinolone injections may bring rapid and dramatic relief of the symptomatology of nonankylosed acute cricoarytenoid arthritis for periods of up to one year if other medical management is adequate. Six cases illustrate the problem and the efficacy of this treatment methodology. Findings, pathology and pertinent literature are discussed. Specific criteria for considering this technique are outlined. This form of therapy has not been described previously.

Blastomycosis is an uncommon fungal disease which may mimic carcinoma of the larynx. Physical examination may show a granular appearance early in the disease with progression to laryngeal fibrosis. Histologic examination usually shows pseudoepitheliomatous hyperplasia, microabscesses, and giant cells. The broad-based budding yeast organisms may be easily overlooked unless special stains are used. Two cases of laryngeal blastomycosis which were originally treated as carcinoma are reported.

Chondrosarcoma of the larynx is a rare malignant tumor sometimes encountered by otolaryngologists. Since they are usually of low grade malignancy, total laryngectomy is indicated only in cases of high grade malignancy or where total excision by conservative (partial) laryngectomy is not feasible. This paper reviews chondrosarcoma of the larynx, discusses a patient who developed this tumor, and describes a method of conservative surgical excision and laryngotracheal reconstruction when the tumor involves the cricoid, the most common site of occurrence in the larynx.

The hemophiliac patient is in constant danger of death from hemorrhage. The danger of bleeding into the submucosal areas of the upper aerodigestive tract, however, does not primarily lie in the blood loss but rather is due to compression and edema of the upper airway. The treatment of choice, in addition to the direct treatment for the specific clotting factor deficiency, is elective nasotracheal intubation, since in most cases this interstitial bleeding, resulting in airway compromise, recedes in four to five days.

Four patients with chronic mucocutaneous candidiasis (CMC) underwent esophagoscopy and microlaryngoscopy. Cultures were obtained by biopsy of the larynx and the esophagus. Three of the four patients with laryngeal disease proven by laryngoscopy and culture also had extensive esophageal disease. One patient with a normal larynx by examination and culture also had a normal esophagus. There appears to be a good correlation between the presence of laryngeal and esophageal disease.

A supraglottic stenosis with postcricoid stenosis was successfully corrected in a single stage procedure by excising the scar tissue and the arytenoid cartilage and the use of mucosal flaps to recover the right side of the larynx and postcricoid area. By obtaining good mucosal approximation without tension the need for a free skin graft or mucosal graft was avoided.

A retrospective comparison of radical and conservative technique for neck dissection in cancer of the larynx was made, starting from analysis of 98 patients operated on with the conservative procedure (128 cervical neck fields at risk of recurrence) at the Istituto Nazionale Tumori of Milan. Furthermore, a series of 162 patients was selected from more than 500 radical neck dissections performed in the past to set up a series as comparable as possible as far as several parameters were concerned. No significant difference was found between radical and conservative neck dissection with regard to the incidence of recurrences in the operative field, either considering the whole series (2.5% versus 1.6%), or cases with histologically proven metastases (9.4% versus 4.5%). Conservative neck dissection seems as safe as radical neck dissection, at least within the limits set in the present study for the indication of the former procedure, ie, nonsuspect nodes or metastatic mobile nodes not greater than 2.5 cm.

On 13 rabbits part of the lateral aspect of the jawbone was frozen with liquid nitrogen in two sessions. The animals were sacrificed 2, 4, 12, and 24 weeks after the cryosurgery. The specimens were analyzed with microangiography according to the Spalteholz technique and with light microscopy. The whole width of the lateral cortex, measuring around 3 mm, was subject to bone destruction two weeks after cryosurgery. New bone formation, on the other hand, was evident in the frozen area and on the undamaged periosteum some distance from the lesion. The same area, 12 weeks after the injury, was completely restored. Bone destruction and regeneration are discussed with special reference to the vascular response to the injury.