Laryngology

Human papillomavirus and tobacco use in tongue base cancers

August 21, 2013     Daniel L. Stoler, PhD; Philip J. Smaldino, MS; Huferesh K. Darbary, PhD; Maureen A. Sullivan, DDS; Saurin R. Popat, MD, MBA; Wesley L. Hicks Jr., MD; Mihai Merzianu, MD; Daniel P. Gaile, PhD; Garth R. Anderson, PhD; and Thom R. Loree, MD, FACS
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Abstract

Human papillomavirus 16 (HPV-16) infection and tobacco use are associated with human oropharyngeal cancers. We conducted a study of the role of HPV and tobacco use in base of the tongue (BOT) cancers. DNA from 34 such cancers was subjected to HPV-16 and HPV-18-specific polymerase chain reaction analysis. Demographic and clinicopathologic data were obtained from each patient's medical record. HPV-16 was detected in 68% of tumors. Tobacco use was the only factor found to be significantly associated with HPV status. Tumors from 100% of patients who had never used tobacco tested positive for HPV, compared with only 56% of those who had ever used tobacco (Fisher exact test, p = 0.024). All tumors were associated with either tobacco use or HPV infection. These findings are consistent with the hypothesis that either tobacco use or HPV infection is necessary to the etiology of BOT tumors, and they suggest that tongue base carcinoma may be prevented by combining HPV vaccination with tobacco avoidance.

Traumatic tracheostomy and spent bullet aspiration after a gunshot injury: A case report

August 21, 2013     Jack Barasa, MD; Peter M. Nthumba, MD; and Peter Bird, FRACS
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Abstract

Penetrating tracheal injuries are rare. Even rarer is the finding of intrabronchial foreign bodies caused by penetrating objects. We report a patient who experienced a gunshot injury to the trachea and mandible. The tracheal wound was debrided and used as a tracheostomy; a spent bullet in the bronchial tree was missed on initial evaluation but later successfully retrieved bronchoscopically. Spent bullet aspiration is a very rare occurrence. A careful examination of radiographs is essential to aid with the diagnosis. Flexible bronchoscopy is the best means of bullet retrieval. Management of any associated injuries is made easier after the airway is secured.

Comparison of complication rates associated with stapling and traditional suture closure after total laryngectomy for advanced cancer

August 21, 2013     Brett A. Miles, DDS, MD; Deborah Larrison, MD; and Larry L. Myers, MD
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Abstract

We conducted a retrospective, matched-cohort, case-control study to compare complication rates associated with two wound closure procedures-stapling vs. traditional hand suturing-following total laryngectomy. Our study population was made up of 42 consecutively presenting patients-38 men and 4 women, aged 34 to 92 years (mean: 60.3) whose pharyngotomies were amenable to primary closure. Of this group, 37 patients had active endolaryngeal squamous cell carcinoma (SCC), 2 patients had inactive endolaryngeal SCC, 2 patients had thyroid cancer, and 1 patient had been treated for chronic aspiration. A total of 26 patients (61.9%) had undergone traditional suture closure of the neopharynx (suture group) and 16 patients (38.1%) had undergone closure with a linear stapling device (staple group). Other than the fact that the patients in the staple group were significantly older than those in the suture group (median: 71.0 vs. 56.5 yr, p = 0.002), there were no significant differences between the two groups in terms of comorbidities or cricopharyngeal myotomy, tracheoesophageal puncture, or neck dissection. There was a total of 8 postoperative infections-5 in the staple group (31.3%) and 3 in the suture group (11.5%)-not a statistically significant difference. Fistulas occurred in 4 staple patients (25.0%) and 6 suture patients (23.1%)-again, not statistically significant. We conclude that in appropriately selected patients, primary closure of the neopharynx can be safely and effectively achieved with a linear stapling device.

Peripheral osteoma of the hard palate

August 21, 2013     Borlingegowda Viswanatha, MS, DLO, PhD
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Abstract

Peripheral osteomas of the hard palate are relatively rare. Two cases of osteoma of the hard palate are reported, along with a review of the literature.

A systematic review of proton-pump inhibitor therapy for laryngopharyngeal reflux

August 21, 2013     Uchechukwu C. Megwalu, MD
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Abstract

The author performed a MEDLINE literature search to identify and evaluate all randomized, placebo-controlled trials of the treatment of laryngopharyngeal reflux (LPR) with an oral proton-pump inhibitor (PPI) that have been published since 1966. Eight such trials that included a total of 358 patients were identified. These eight studies contained seven different definitions of LPR. Validity scores (maximum: 9) ranged from 5 to 9 (mean: 7.5). One study investigated low-dose once-daily therapy, two studies investigated low-dose twice-daily therapy, and five studies investigated high-dose twice-daily therapy. Outcomes measures were not consistent among studies, and most studies used unvalidated outcomes measures. Only two studies found that a PPI was significantly better than placebo-one in the low-dose twice-daily group and one in the high-dose twice-daily group. The author concludes that the current body of literature is insufficient to draw reliable conclusions about the efficacy of PPI therapy for the treatment of LPR.

Primary laryngeal actinomycosis in an immunosuppressed woman: A case report

July 21, 2013     Tarik Abed, MBBS; Jay Ahmed, MBBS; Niamh O'Shea, MBBS; Simon Payne, FRCPath; Gavin W. Watters, FRCS
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Abstract

We report a rare case of primary laryngeal actinomycosis, which occurred in a 35-year-old woman with end-stage renal failure secondary to systemic lupus erythematosus with membranous glomerulonephritis. The patient, who had been on long-term immunosuppression therapy, presented with hoarseness. Flexible laryngoscopy detected the presence of a granular glottic mass at the anterior commissure of the larynx. Histology revealed actinomycotic organisms associated with an abscess. The patient was treated with a prolonged course of oral penicillin V and speech therapy, and her dysphonia resolved almost completely. Although actinomycotic infection of the larynx is rare, it should be considered in the differential diagnosis of hoarseness in an immunocompromised patient.

Synovial sarcoma of the larynx treated by supraglottic laryngectomy: Case report and literature review

July 21, 2013     Kuauhyama Luna-Ortiz, MD; Ana Maria Cano-Valdez, MD; Isabela Werneck da Cunha, MD; Adalberto Mosqueda-Taylor, DDS
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Abstract

We describe a case of synovial sarcoma of the larynx, and we discuss the use of fluorescence in situ hybridization (FISH) in confirming the diagnosis. The patient was a 21-year-old woman who presented with a recurrence of a previously resected supraglottic tumor of the aryepiglottic folds. A horizontal supraglottic laryngectomy was performed, and the 0.5-cm tumor was resected. Histopathologic study suggested that it was a biphasic malignant tumor compatible with a synovial sarcoma. The diagnosis of synovial sarcoma was confirmed by FISH immunohistochemistry with the use of an SYT break-apart probe. The patient recovered satisfactorily, but at follow-up 5 years and 4 months later, tumoral activity was evident in the left side of the neck. A biopsy found that 5 lymph nodes contained a metastasis of the synovial sarcoma. Again, a bilateral neck dissection was performed, and it revealed that 16 of 16 right-side nodes and 36 of 36 left-side nodes were negative. Two months later, the patient received 46 Gy of radiotherapy in 23 sessions. She remained free of disease during 2 more years of follow-up. Synovial sarcoma of the larynx is a rare entity. Organ preservation seems to be indicated in these cases. The histologic diagnosis may be difficult. In this case, the identification of a genetic mutation corroborated the diagnosis.

Laryngotracheal rhinosporidiosis

July 21, 2013     J. Madana, MS; Deeke Yolmo, MS; S. Gopalakrishnan, MS; Sunil K. Saxena, MS
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Abstract

Rhinosporidiosis is a chronic granulomatous disease caused by Rhinosporidium seeberi. It usually affects mucous membranes of the nose, nasopharynx, and ocular conjunctiva. Cutaneous, laryngeal, tracheal, genital, and bony dissemination is rare. Laryngotracheal involvement poses many diagnostic and therapeutic challenges. A 45-year-old South Indian man presented with complaints of a mass in both nostrils for 2 years, associated with progressive hoarseness of voice and difficulty in breathing for 6 months. Rhinosporidial lesions were seen bilaterally in the nasal cavity. Telescopic and fiberoptic laryngoscopic examinations showed reddish, strawberry-like masses with whitish spots on their surface involving the larynx and trachea. Computed tomography of the head and neck revealed soft-tissue mass lesions involving the bilateral nasal cavities and nasopharynx, extending to the oropharynx and involving the larynx and trachea. A preliminary tracheostomy was performed, followed by direct laryngoscopic excision of the laryngeal lesions and rigid-bronchoscopy-guided excision of the tracheal lesions. The patient was prescribed dapsone and advised to take it for 2 years. At 2 years of follow-up, there was no recurrence.

Posterior cordectomy: How much is enough?

July 21, 2013     Reena Gupta, MD; Belinda Mantle, MD; Ryan F. Osborne, MD
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Bilateral vocal fold paralysis has traditionally been treated with tracheotomy, which bypasses the source of obstruction and exerts a lesser impact on swallow function compared with other interventions, but fewer patients are willing to tolerate this option.

Unusual pseudomyiasis with Musca domestica (housefly) larvae in a tracheostomy wound: A case report and literature review

July 21, 2013     Mohammad Shakeel, MS; Iram Khan, MD; Imteyaz Ahmad, MD; Zafar Iqbal, MS; Syed Abrar Hasan, MS
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Abstract

We report a case of pseudomyiasis (accidental myiasis) in a 52-year-old man who had previously undergone surgery and placement of a tracheostomy tube for laryngeal cancer. The patient presented to our outpatient department with a foul-smelling, blood-stained discharge and frequent and severe episodic pain at the site of the tracheostomy. He also reported the discharge of many whitish larvae from the site. On clinical examination, 3 of these larvae were removed from the tracheostomy wound and later identified as Musca domestica (housefly) larvae. The patient underwent further mechanical removal twice daily for 3 days, during which time 23 more larvae, or maggots, were removed. His condition improved, and he returned for regular follow-up with no recurrence or complications. Myiasis is an infestation of humans and vertebrate animals by insect larvae that feed on both dead and living tissue. Myiasis is most common in hot and humid climates in tropical and subtropical regions, such as the underdeveloped areas of India, Africa, and Southeast Asia, which provide favorable breeding grounds for flies. Myiasis is classified as specific, semispecific, or accidental, depending on whether the fly larvae require a host in order to develop. We review the literature on myiasis and its entomologic aspects in general. We also discuss the need for the proper care of tracheostomy wound myiasis because the site of such an infestation is close to vital organs in the neck. To the best of our knowledge, only 3 cases of tracheostomy wound myiasis have been previously reported in the English-language literature; 2 of them involved infestation with Chrysomyia bezziana larvae and 1 with Lucilia caesar larvae. We believe our case is the first case of tracheostomy wound pseudomyiasis attributable to M domestica larvae.

Tonsillar Kaposi sarcoma in a patient with membranous glomerulonephritis on immunosuppressive therapy

July 21, 2013     Nabeel Al-Brahim, FRCPC; Ashraf H. Zaki, MD; Khaled El-Merhi, MD; Mahmoud S. Ahmad, MD
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Abstract

Kaposi sarcoma is a malignant vascular neoplasm uncommonly seen in immunosuppressed patients. Herein we report an unusual case of tonsillar Kaposi sarcoma in a patient with membranous glomerulonephritis treated with prednisolone and cyclosporine. The patient presented after 10 months of starting the treatment with a tonsillar mass. Histological examination was typical of monomorphic spindle cell proliferation with slit-like vascular channels. The tumor cells expressed CD34, D2-40 and positive nuclear stain for HHV-8. Kaposi sarcoma is associated with immunosuppression and rarely occurs in the tonsil. Clinicians should be aware of this rare presentation of Kaposi sarcoma.

Spindle cell lipoma of the larynx

June 11, 2013     Antonio D'Antonio, MD, PhD; Giampiero Mottola, MD; Alessia Caleo, MD; Maria Addesso, MD; and Amedeo Boscaino, MD
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Abstract

Among the primary mesenchymal tumors of the hypopharynx and larynx, lipomas are rare. Macroscopically, they often resemble a retention cyst or laryngeal nodule. Spindle cell lipomas (SCLs) are an uncommon variant of lipoma. SCLs are extremely rare in the larynx; as far as we know, only 4 cases have been previously described in the literature. We present a new case of laryngeal SCL in a 65-year-old man who presented with a 1-year history of hoarseness, choking spells, stridor, and dyspnea. Examination revealed the presence of a large polyp on the left true vocal fold that had caused stenosis of the posterior glottis. The polyp was removed endoscopically, and the patient's stridor and dyspnea resolved. Histologically, the tumor was composed of bland, CD34-positive spindle cells with an abundant fibrous and myxoid stroma interspersed with mature fatty tissue. The patient was free of local recurrence at 2 years of follow-up.

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