Primary angiosarcoma of the larynx: a rare entity

Angiosarcomas are extremely rare malignant tumours of the larynx. We present a case of laryngeal angiosarcoma in a 58-year-old man who presented with hoarseness of voice, dysphagia and neck swelling. The patient underwent a total laryngectomy with a pre-operative and frozen section diagnosis of a poorly differentiated carcinoma of the larynx. Histopathological and immunohistochemical evaluation revealed features of a laryngeal angiosarcoma. The case is presented for its rarity and diagnostic difficulty.     

Laryngeal Dysplasia,Squamous Cell Carcinoma,and Variants

Squamous cell carcinoma (SCC) is a malignant epithelial tumor showing evidence of squamous differentiation. It is the most common malignancy of the larynx, with several variants (verrucous, exophytic or papillary, spindle-cell, basaloid, acantholytic, adenosquamous) recognized, with well-established precursor lesions. Dysplasia is now separated into only low-grade and high-grade categories. Each SCC variant has unique cytomorphologic features and histologic differential diagnoses that are important to consider, as management and outcomes are different.     

Laryngeal neurophysiology and its clinical uses

A fact well known to all otolaryngologists, but which occasionally bears repeating, is that the larynx is not just an organ of communication. The larynx sits at the crossroads of the pathways of air and food intake, and serves the vital function of keeping ingested food and water from entering the lungs. Another obvious consideration, however, is that if the larynx were not there and if the breathing and alimentary passages were totally separate (as after surgical laryngectomy), then there would be no need for the larynx other than to speak. Thus, in terms of survival of the organism, laryngectomy can be considered a viable treatment option any time laryngeal dysfunction compromises health. The problem with this line of reasoning, of course, is that speech, in humanistic terms, is a very compelling need. Someone who communicates in any mode other than that of normal speech is at a distinct disadvantage in almost any culture. Therefore, at its essence, the subspecialty of laryngology has as its central mission the preservation or restoration of normal voice and speech by the natural mechanism. In accomplishing this, it is necessary to understand how the larynx functions as an integral component of the systems for speech, breathing, and swallowing. The intent of this article is to outline essential features of laryngeal function, to describe how function is impaired by diseases, and to offer examples of the clinical significance of this information. HEAD & NECK 1996;18:78–86 © 1996 John Wiley & Sons, Inc.     

The use of the carbon dioxide laser in the pediatric airway.

Congenital and acquired lesions of the pediatric airway present difficulties in management. Until recently, correction of these problems frequently involved an external approach to the larynx and trachea. Development of fiberoptic instrumentation, as well as the introduction of the Zeiss operating microscope, has now given the surgeon a new means to visualize the larynx and trachea. Soon after its development, the carbon dioxide surgical laser was coupled to these instruments to permit an extremely precise form of tissue excision and ablation. Its unique properties, including an extraordinary hemostatic effect, as well as minimal postoperative edema and scarring, make it an ideal tool for management of lesions of the pediatric airway. It has been employed successfully in the treatment of 177 lesions.     

Laryngeal chondrosarcoma: gross pathological, histologic and electron microscopic characteristics

Chondrosarcoma is an uncommon cartilaginous tumour of the upper respiratory tract, and its morphology and clinical course vary widely. Few reports have evaluated the clinicopathological findings of this tumour in the larynx. This paper reports on a low-grade chondrosarcoma in a 44-year-old woman who required laryngectomy for cure. The gross pathological, histologic and electron microscopic features of the tumour are analysed with respect to its clinical course, using histopathological criteria.     

Sebaceous carcinoma of the lung: histologic and immunohistochemical characterization of an unusual pulmonary neoplasm: report of a case and review of the literature

Sebaceous neoplasms, including carcinomas, are tumors most often seen around the eye and eyelid. Cases of extraorbital sebaceous tumors associated with skin adnexa are less common. The parotid gland may also be a source for sebaceous neoplasms, and cases associated with minor salivary gland tissue have also been reported. Once beyond the oropharynx, individual cases of pharyngeal and laryngeal sebaceous tumors are reported. The case of a patient with primary sebaceous carcinoma of the bronchus is presented. Our case is that of an endobronchial mass that has histopathologic features of a sebaceous carcinoma, with predominance of areas with morphologically classic sebaceous differentiation, confirmed by oil red O stain for lipid, analyzed by immunohistochemistry and evaluated ultrastructurally. This unique tumor extends the spectrum of extraocular, extracutaneous neoplasms with sebaceous differentiation from existing single reports in the hypopharyx and larynx to now include bronchus.     

Surgical treatment of carcinoma of the hypopharynx and cervical esophagus

This paper discusses several recent advances in surgical methods for treatment of cancer of the hypopharynx and cervical esophagus. The standard surgical technique for the primary lesion is laryngo-pharyngo-esophagectomy in which the larynx is usually resected to prevent postoperative aspiration even if the cancer does not directly involve the larynx. Another common technique is total laryngectomy plus partial resection of the hypopharynx, where a very limited lesion in the unilateral pyriform sinus is resected with the surrounding hypopharyngeal mucosa and larynx. In this case, the defect in the hypopharyngeal mucosa is primarily sutured or reconstructed with a graft based on its size. Experience has demonstrated that the larynx can be preserved without any postoperative aspiration if it is not involved by cancer and surgeons design the lines of resection and the postoperative shape of the reconstructed area to prevent aspiration. It has also been demonstrated that even if a part of the larynx is involved and must be resected, the remaining portion of the larynx can sometimes be preserved without any distinct aspiration. There are two common surgical techniques for neck lymph nodes. Radical neck dissection is the classic one, in which the lymphatic tissues together with the surrounding structures, including the sternocleidomastoid muscle, internal jugular vein, and accessory nerve are resected. Conservative neck dissection resects the lymphatic tissues only and preserves other structures. Currently, the standard surgical technique is conservative neck dissection. Radical neck dissection is rarely performed now because its morbidity is much higher and its superiority in treatment results has not been established.     

Vocal cord paralysis from prostatic carcinoma metastasizing to the larynx

According to 1992 Cancer Statistics, prostate carcinoma is once again predicted to be the most common cancer in men, exceeding the incidence of lung cancer. In American men, this cancer is estimated to be the second most frequent cause of cancer deaths by site. Although metastases have been reported in practically every organ in the body, prostatic cancer most often metastasizes to bones, regional lymph nodes, and viscera. Although secondary involvement of the larynx by malignant neoplasms arising in contiguous structures is well known, metastatic cancer to the larynx from a prostate carcinoma is rare. This report discusses a unique case that presented with hoarseness resulting from vocal cord paralysis. The diagnosis of the tumor was confirmed by immunoperoxidase stains for prostate-specific antigen.     

Denture mimicking vocal cords--a rare entity. A case report

Laryngeal foreign bodies are not uncommon. A common difficulty encountered is a delay in diagnosis. The clinical features of a laryngeal foreign body may simulate asthma in an adult. The differentiation is necessary in the initial stages as the laryngeal foreign body can lead to sudden death due to airway obstruction. Sudden onset of wheeze in a non-asthmatic patient should arouse its suspicion. A case is reported where patient was transferred to respiratory intensive care unit for respiratory distress with wheeze which was later diagnosed as foreign body larynx.     

Chondrosarcoma of the larynx: a case report and review of the literature

Chondrosarcoma of the larynx is a rare disease. The condition usually presents as a space-occupying lesion in the larynx. It is usually internal, but an external mass may be noted. Diagnosis demands a deep biopsy as the tumour is submucosal. Treatment is surgical, but the extent of this surgery is dependent upon the stage of the disease. The prognosis, in most cases, is usually very good. The literature relating to chondrosarcoma of the larynx is reviewed and salient features are presented. Added interest in this case is due to the long precedent history and the difficulty in obtaining a diagnosis.     

Acute Airway Obstruction Secondary to Vocal Fold Heterotopic Ossification

A 29-year old man of Eritrean origin presented with acute stridor and respiratory distress on a background 1 year history of progressive breathing difficulty and worsening inspiratory stridor. Fibreoptic laryngoscopy revealed an indeterminate swelling of the left vocal fold leaving no clear airway visible. The patient refused surgical tracheostomy. Microlaryngoscopy revealed a hard, calcified mass arising from the left cord preventing intubation. Histological analysis after excision revealed features consistent with heterotopic ossification. At 4 months repeat microlaryngoscopy was performed revealing normal appearance of the larynx and subglottis. Heterotopic ossification in the larynx is a very rare condition that presents a diagnostic and therapeutic challenge. In the first documented case in the larynx, we describe how the disease caused life threatening airway obstruction, but was managed in a way that led to preservation of laryngeal function and complete resolution of the condition.     

Primary laryngeal T-cell lymphoma: A case report and review of the literature

IntroductionPrimary lymphoma of the larynx is extremely rare, representing less than 1% of all primary laryngeal neoplasms. It consists mainly of non-Hodgkin lymphomas (NHLs), represented particularly by diffuse large B-cell. Extranodal natural killer/T-cell lymphoma, presented in larynx is a rare condition that accounts for less than 11% of all lymphomas without distinctive clinicopathologic features, as well as challenging pathologic diagnosis.Case reportWe report here a case of a 64-years-old man who presented with primary lymphoma type T of the subglottic larynx. A histopathological examination of the biopsy confirmed non-Hodgkin T cell lymphoma. Given his age, he underwent chemotherapy and radiation therapy. The patient was disease-free after 18 months follow up.ConclusionThe clinicopathological characteristics and rational treatment of primary laryngeal lymphoma are still unclear and need to be further defined due to the paucity of this pathology.     

Multiple soft tissue aneurysmal cysts: An occurrence after resection of primary aneurysmal bone cyst of fibula

We report a case of multiple extraosseous aneurysmal cysts occurring in the muscle and subcutaneous plane of postero-lateral aspects of the upper right leg. They appeared about 15 months after resection of aneurysmal bone cyst of the upper end of the fibula. They varied in size from 2 cm to 5 cm. Radiologically they were well-defined lesions with central septate areas surrounded by a rim of calcification. Histologically they showed central cystic spaces separated by septa consisting of fibroblasts, osteoclast type of giant cells and reactive woven bone. Thus they showed histological similarity with aneurysmal bone cysts, but did not show any connection with the bone. Only very few examples of aneurysmal cysts of soft tissue had been described in the past one decade and they were reported in various locations including rare sites such as arterial wall and larynx. Recent cytogenetic analyses have shown abnormalities involving 17p11-13 and/or 16q22 in both osseous and extraosseous aneurysmal cysts indicating its probable neoplastic nature. Our case had unique features like multiplicity and occurrence after resection of primary aneurysmal bone cyst of the underlying bone.     

Dietary factors for cancer of specific sites

Even though the issues have been greatly simplified in this article by citing of only the most salient data, when a number of different cancers are examined, a diverse range of dietary factors is implicated. For a number of cancers, very little is known, and for others, competing hypotheses are supported by conflicting data. Despite these obvious limits, some generalizations regarding common patterns of risk at different cancer sites may be possible. For example, although the nutrients and mechanisms may vary by site, lack of consumption of fruits and vegetables has been linked repeatedly to cancers of the mouth, larynx, esophagus, and lung. A similar association is suggested for cancers of the cervix and bladder. Another commonality is the association of dietary fat with cancers of the breast, ovary, prostate, and, possibly, colon. Alcohol is associated with cancers of the mouth, larynx, and, possibly, rectum. Coffee has been studied in association with cancers of the pancreas, ovaries, and lungs, but few of these studies have been replicated and the role of this common dietary exposure remains in question. In most other instances, unique cancers are linked to unique dietary exposures, for example, fiber and colorectal cancer or nitrates and stomach cancer. Given that both common and unique sources of dietary risk may be identified for different cancers, future research may benefit from a two-pronged research strategy. Basic nutrients need to be examined for multiple cancers, and specific aspects of diet require in-depth study for specific cancers. From such an approach, it may be possible to resolve some of the questions and issues reviewed herein.     

Computed tomography evaluation of the nasal septal reconstructed larynx

Computed tomography (CT) of the larynx was performed in 15 patients who had their larynx reconstructed by composite nasal septal autograft after frontal, or frontolateral laryngectomy. Five representative cases each with CT scan and additional laryngoscopic documentation are presented. The CT permitted a detailed appraisal of the nasal septal grafted larynx. Our attention was directed to the image of the graft in what concerned its patterns of distortion, fibrosis or chondrification, and width of the laryngeal airway. The scan from 10 patients brought radiographic evidence that the implanted cartilage retained vitality and structural integrity.     

The immunology of composite tissue transplantation

Composite tissue allotransplantation holds great potential for reconstructive surgery. That these procedures can be successful has been clearly demonstrated by the success of hand, face, and larynx transplants around the world. Although the immunology of composite tissue allotransplantation mirrors that of any allogeneic organ transplant, there are several unique aspects to these grafts. This article reviews the immunology of transplantation, histocompatibility testing for composite tissue allotransplantation, graft rejection, immunosuppression, and specific immunologic considerations of composite tissue allotransplantation.     

Rehabilitation outcomes of long-term survivors treated for head and neck cancer

Background. Little is known about the rehabilitation outcomes of long-term survivors following treatment for head and neck cancer. There are, for example, no studies on physical and psychosocial rehabilitation outcomes of T1 glottic larynx carcinoma, despite the fact that these form the majority of head and neck cancer sites. Thus, this investigation afforded a unique opportunity for examining similarities and differences among T1 glottic larynx patients, laryngectomy patients, and those who had surgery for cancer of the oral cavity and/or oropharynx along a variety of physical and psychosocial dimensions. Methods. To describe the impact of these three types of head and neck cancer and their treatment on the physical and psychosocial functioning of long-term survivors, a selfreport questionnaire was completed by 110 patients treated between 2 and 6 years previously in a major cancer center. Results. Data indicate that a higher percentage of patients treated with laryngectomy or commando procedures still experience severe psychosocial distress between 2 and 6 years after their last treatment than do patients treated with radiotherapy for a T1 carcinoma of the glottic larynx. Psychosocial and physical complaints are still reported by many laryngectomy patients, apparently the result of problems in effective communication with others. Many commando procedure patients experience problems with respect to food intake, and with disfigurement and its consequences. T1 Iarynx patients mainly experience a considerable number of physical complaints. The greater the time that had elapsed since treatment, the fewer the psychosocial problems associated with head and neck tumors. Open discussion of the illness in the family, social support, and perceptions of adequate information from the specialist are the most important predictors of positive rehabilitation outcomes. Conclusions. This study indicates that T1 Iarynx patients report many physical complaints even though several years had elapsed since treatment. Also, Iaryngectomy patients may need psychosocial guidance for a longer posttreatment period and that health care personnel must involve the partner as much as possible in all communications. Commando procedure patients in particular feel hindered by their disfigurement and its consequences. Future research with respect to validation of the specific head and neck modules is needed.     

A new instrument to expose the human larynx.

OBJECTIVE: To present a nonwalled all-detachable retractor that simultaneously exposes the mouth, pharynx, and larynx. STUDY DESIGN AND SETTING: The proposed instrument is composed of a mouth-gag with a set of 5 interchangeable angled tongue blades, and a pharyngeal lever that provides internal laryngopharyngeal distension. Sixty-five patients were submitted to tonsillectomy, adenoidectomy, and endolaryngeal surgery with the workspace provided by the manufactured scope. RESULTS: Proper exposure of the upper aerodigestive tract was achieved in all patients. Naked eye, varied endoscopes, and special curved instruments were used to examine, lase, and manipulate tissues. Bimanual surgery was possible due to self-retaining adjustment and a clamp for endoscopes. CONCLUSION AND SIGNIFICANCE: This instrument allowed for an ample exposure from mouth to glottis in adults and children. Opposed to linear laryngoscopes in which the patient adapts to the instrument, its unique design adjusts to patients' anatomy and to many clinical situations.     

Primary mucosa-associated lymphoid tissue (MALT) lymphoma of the larynx

BACKGROUND: Mucosa-associated lymphoid tissue (MALT) lymphoma is usually associated with a chronic inflammatory disease from which lymphoid tissue of MALT type arises as a prerequisite for lymphoma proliferation. No well-characterized chronic inflammatory process has been identified in the larynx. METHODS: We report a case of primary MALT lymphoma of the larynx associated with extraesophageal reflux, chronic laryngitis, and gastric Helicobacter pylori infection, raising the issue of its physiopathology and treatment. RESULTS: Treatment of this MALT lymphoma of the larynx consisted of complete surgical excision associated with omeprazole, amoxicillin, and clarithromycin. No evidence of disease was observed after 24 months of follow-up. CONCLUSIONS: We may assume that chronic laryngitis could be a precursor to MALT lymphoma. This case is the first one to our knowledge of a primary MALT lymphoma of the larynx treated with conservative management combining surgical excision, reflux therapy, and eradication of gastric H. pylori infection.