Neck crepitance: evaluation and management of suspected upper aerodigestive tract injury

OBJECTIVE: To determine safe criteria for the management of patients with crepitance of the neck. HYPOTHESIS: Upper aerodigestive tract injury may lead to significant morbidity and mortality. Historically, this kind of injury has been managed by immediate surgical exploration, repair, and drainage. More recently, a nonoperative approach has been advocated. STUDY DESIGN: Retrospective chart review of patients admitted to the University of Louisville Trauma Center with suspected upper aerodigestive tract injury. METHODS: We reviewed the charts of 236 patients admitted to the trauma service from 1995 to 1999 with the diagnosis of aerodigestive tract injury or subcutaneous emphysema. RESULTS: Nineteen patients were identified with cervical emphysema or cervical crepitance, or both, thought to be caused by an upper aerodigestive tract injury. The average patient age was 38.5 years; 68% of patients were men. The mechanisms of injury were motor vehicle accident (43%), gunshot wound (37%), assault (10%), blunt neck trauma (5%), and stabbing (5%). Each patient presented with cervical emphysema shown by radiograph or crepitance, or both; 21% had dysphagia and 63% were hoarse or had stridor. Location of the injury was tracheal or laryngeal in 37%, hypopharyngeal in 27%, oral pharynx in 16%, esophageal in 5%, and unidentified in 15% of patients. Because of suspected aerodigestive tract injury, 79% of patients were taken to the operating room for direct laryngoscopy and esophagoscopy, and abnormalities were found in 80%. The diameter of the average laceration of the upper aerodigestive tract was 1.6 cm. Associated injuries included mandible fractures in 37% of patients. Broad-spectrum antibiotics were given to 95% of the patients. The initial management involved immediate surgical exploration in 55% of the total number of patients, with 83% of the surgically explored patients undergoing tracheotomy. The remaining 45% of patients were managed without surgery. Complications occurred only in operative patients, with aspiration occurring in 10%, bilateral hypoglossal nerve paralysis in 5%, and vocal cord paralysis in 5%. None of the patients developed postinjury or operative abscess. CONCLUSION: The findings show that suspected upper aerodigestive tract injury can be managed without surgery but that a high index of suspicion for airway compromise and associated facial injuries must be considered.     

Unusual presentations of foreign body in aerodigestive tract

Foreign bodies lodged in aerodigestive tract makes the commonest emergency in the otorhinolaryngology clinics. Diagnosis often becomes difficult with parental ignorance and lack of clear history. Patients with foreign body can have unusual presentations.     

Impact of re-resection for inadequate margins on the prognosis of upper aerodigestive tract cancer treated by laser microsurgery

OBJECTIVES: Positive or uncertain surgical margins left untreated have a distinct prognostic relevance in squamous cell carcinoma of the upper aerodigestive tract. An advantage of transoral laser microsurgery is that it can be easily repeated if inadequate resection margins are found postoperatively. The present study investigates the impact of laser surgical reresection on the outcome of patients. STUDY DESIGN: The authors conducted a retrospective unicenter study. METHODS: A review of 1,467 patients with squamous cell carcinoma of the upper aerodigestive tract who were initially treated by transoral laser microsurgery with curative intent between August 1986 and December 2002 was conducted. Locoregional control as well as TNM adjusted and overall survival were analyzed using the Kaplan-Meier method. RESULTS: Three hundred eighty-six patients have required reresection to obtain clear surgical margins, in 70 of whom residual carcinoma has been detected in revision specimens. Patients without need for revision and those in whom revision specimens were found tumor-free had an almost identical locoregional control (P = .4611). In patients with positive revision specimens, however, locoregional control was significantly worsened (P = .0058). Neither the need for reresection nor the detection of further tumor tissue in revision specimens affected TNM adjusted or overall survival. CONCLUSIONS: Survival of patients was similar whether clear resection margins were reached within the first surgical step or with revision surgery. However, patients in whom reresection specimens contained residual carcinoma had an increased risk of locoregional failure and should undergo a further reresection or at least a very close follow up.     

头颈部淀粉样变性23例临床分析

目的 探讨头颈部淀粉样变性的临床表现、诊断、治疗和预后。 方法 对南京医科大学第一附属医院2007年4月至2018年10月收治的23例头颈部淀粉样变患者的临床资料进行回顾性分析并总结。 结果 23例患者均行手术治疗,其中16例为原发性局部性淀粉样变,7例为继发性局部性淀粉样变。术后随访5个月至11年,其中2例多发性局部淀粉样变患者术后复发,表现为声嘶及咽部异物感,5例失访,余患者未见明显复发。 结论 头颈部淀粉样变性临床表现多变,内镜下形态无特异性,确诊依赖于病理切片刚果红染色;该病症发展缓慢,有复发倾向;治疗应根据病变范围选择合理术式并彻底切除病灶,术后需长期随访观察。     

咽喉淀粉样变性的治疗及预后的观察分析

报告５例咽喉淀粉样变性病例。３例手术切除随访１至５年，无复发。１例从诊断至今已３０余年，目前已８６岁生活仍能自理。复习文献资料，讨论了目前对这一进展缓慢的良性疾病的认识和治疗意见，认为完全切除是较好的治疗方法。     

Amyloidosis in the upper aerodigestive tracts.

The upper aerodigestive tracts, particularly the larynx, are not uncommon repositories for amyloid. In most instances amyloidosis of the larynx is localized and is not associated with or followed by systemic disease. Oral and nasopharyngeal amyloidoses, on the other hand, are very often manifestations of systemic predisposing disorders. Laryngeal amyloidosis is treated, when indicated, by surgical removal, often repeated because of persistence or multifocal deposits.     

Nocardiosis of the upper aerodigestive tract

Nocardia asteroides is the major cause of nocardiosis in the respiratory tract. The primary site of infection is the lung, with the upper aerodigestive tract being a rare region for localized disease to occur. We describe a case of a nocardial vallecular cyst and discuss the diagnosis and management of this unusual infection.     

Unusual foreign bodies of the aerodigestive tract

Foreign bodies in the aerodigestive tract are familiar ototaryngological emergencies. The diagnosis and the management in most cases is based an clinico- radioloigical findings. Three cases of foreign body in the nerodigestive tract with unusual presentation are being described here.     

Condylomatous lesions of the upper aerodigestive tract

Condyloma acuminatum is one of four types of common human verrucous lesions that are of viral etiology. Also known as "moist wart," condyloma acuminatum is most often seen on the mucosal surfaces of the anogenital area. However, occurrences in the mucosal lined areas of the head and neck region are quite rare. Since 1901, 30 cases of condylomatous lesions have been reported in the upper aerodigestive tract, occurring mainly in the various regions of the oral cavity. Eighteen of the cases were confirmed by histopathologic documentation, while the remainder were anecdotal. We have recently encountered six new cases of condyloma acuminatum, verified by histologic examination. One occurred on the tongue, another in the tonsillar fossa, one in the hypopharynx and three on the vocal cords. We present these cases and review the previously reported cases. In addition, we will discuss the differential diagnosis of these lesions, and their importance to the practicing otolaryngologist.     

Locally recurring extramedullary plasmacytoma of the upper aerodigestive tract

BACKGROUND: Extramedullary plasmacytomas (EMP) are plasma cell tumors in which by definition the primary tumor is extramedullary. Most of them are found in the upper aerodigestive tract. PATIENTS: In this study we describe 3 patients with EMP. The first case is a locally recurrent EMP with recurrent involvement of cervical lymph nodes. The first manifestation of EMP was 31 years ago. Hence, this is one of the longest clinical courses of recurrent EMP ever described in the literature. Case 2 is a locally aggressive recurrent EMP. Case 3 is a localized solitary EMP that could be successfully treated by surgery alone. RESULTS AND CONCLUSIONS: Different classifications of EMP described in the literature are discussed. If these classifications are applied to our cases neither the tumor stage nor the histological picture allow definite conclusions about the prognoses to be drawn. Metastases in regional lymph nodes do not necessarily mean a worse prognosis. Overall, compared to MM with a ten year survival rate of 18% the prognosis is more favorable in EMP with a ten year survival rate of 50%. After a generalized plasma cell neoplasia has been excluded EMP in the head and neck should be treated like a locally aggressive and potentially metastatic tumor. From our experiences we recommend a primary surgical therapy followed by radiation therapy if necessary.     

Surgical complications in cancers of the upper aerodigestive tract

The present paper studies the post-operative complications encountered in 300 patients of various upper aerodigestive tract malignancies who were surgically treated. The complications encountered included wound sepsis with or without a fistula, aspiration penumonitis, chylous leak, meningitis, secondary haemorrhage, pleural injury, tracheal tear and tetany. Advanced disease, salvage surgery following radiation failure and positive resected margins were found to adversely affect the complication rate. Ways and means to prevent and treat the above complications are also discussed.     

Caustic ingestion injuries of the upper aerodigestive tract.

Few reports have described in detail the injuries that occur to the oral cavity, pharynx, and larynx following caustic ingestion. The role of dynamic radiographic studies to delineate the extent of damage has been minimized. In-depth radiographic analysis of such cases has not, to our knowledge, been previously reported. In order to examine the injuries and functional abnormalities of these sites following caustic ingestion, the records of The Johns Hopkins Swallowing Center were reviewed. Five patients were identified as having significant upper aerodigestive tract caustic injuries. All patients had dysphagia, epiglottis injuries, and incomplete laryngeal protection with aspiration. Four of five had sustained some degree of esophageal stenosis. Also noted were pharyngeal muscle dysfunction, nasopharyngeal regurgitation, tongue fixation, and hypopharyngeal stenosis. Roentgenographic findings are described and illustrated. The multidisciplinary approach to the management and rehabilitation of these patients is discussed.