David Myssiorek

Recurrent laryngeal nerve paralysis: anatomy and etiology

Etiologies of adult vocal paralysis are varied by the site of the lesion as well as the extent and cause of the damage. Most large series point to surgery and neoplastic causes for recurrent nerve paralysis. A detailed history is important when working up a patient with this voice disorder. Knowledge of the anatomy of the head, neck, and chest as well as the mechanisms behind vocal fold paralysis is essential in the evaluation and treatment of recurrent nerve paralysis. Many of the surgical and traumatic causes of hoarseness are from compression type injuries. Recovery is dependent on the type, extent, and site of nerve lesion. Familiarity with this data allows the otolaryngologist to tailor management to suit each patient with vocal fold paralysis.

Head and neck paragangliomas: An overview

Paragangliomas of the head and neck are unique tumors. Their pathology, tissue of origin, location, genetics, potential for bio-chemical activity, multicentricity, and growth pattern are unusual compared with more common head and neck tumors. Because these tumors are widespread and can appear in the ear, neck, larynx, nose, orbit, and chest, they cross subspecialties of otolaryngology.

Laryngeal paraganglioma: an updated critical review.

Laryngeal paragangliomas are rare submucosal lesions that arise from paraganglion cells located in the false vocal fold and subglottic larynx. To date, 76 recognized cases have been reported in the world literature. Symptoms arise when the lesions become large enough to impair function. Supraglottic paragangliomas cause hoarseness and deglutition disorders, whereas subglottic tumors become symptomatic when they obstruct the airway. Evaluation of these tumors includes obtaining a complete history. Familial paragangliomas and hypertension should be sought but are rarely, if ever, associated with laryngeal paragangliomas. MRI can detect these lesions and permit characterization of the vascularity of the lesion. Adding 111In pentetreotide scanning can distinguish neuroendocrine tumors from other submucosal laryngeal lesions, making the preoperative diagnosis clearer and obviating the need for biopsy. The biggest dilemma regarding laryngeal paragangliomas is making the correct pathologic distinction between paraganglioma, typical carcinoid, atypical carcinoid and medullary thyroid cancer. Immunohistochemical markers, supplementing standard histopathologic evaluation, can distinguish paragangliomas from the aforementioned tumors. This distinction is critical as the prognosis for treated paragangliomas is excellent compared to that for other neuroendocrine neoplasms. Almost all alleged malignant paragangliomas of the larynx are in reality atypical carcinoid tumors that have been misdiagnosed. Treatment should always comprise excision. Thyrotomy has the best chance of achieving a sustained cure without damaging phonation or deglutition. Laser excision has been used successfully but there is no great experience with this modality. Surgery is preferable to radiation for paragangliomas in all locations but especially so in the larynx, due to issues such as swelling, airway protection and destruction of cartilage. With increased clinical suspicion and the use of modern imaging techniques, laryngeal paragangliomas should be routinely diagnosed and treated without loss of laryngeal functions.

111Indium pentetreotide scan detection of familial paragangliomas.

Approximately 10% of head and neck paragangliomas are familial. Magnetic resonance imaging (MRI) is reported to be the best method for screening these families. 111Indium pentetreotide (Octreoscan®) scintigraphy has been shown to be a sensitive indicator of neural crest tumors such as paragangliomas. Early diagnosis and treatment of familial paragangliomas (FP) would decrease the morbidity of tumor excision. Patients from two kindred with FP were scanned 24 hours after intravenous injection with approximately 6 millicuries of 111Indium pentetreotide. The entire body was imaged. Areas of increased uptake were further imaged with MRI. Altogether, five patients had positive 111Indium pentetreotide scans. Two unsuspected glomus tympanicums and bilateral carotid body tumors were identified. Three people tested had no abnormal uptake. There were no untoward reactions to the nuclide. 111Indium pentetreotide scanning is a safe, noninvasive method for early diagnosis of FP and is useful in detecting multicentric lesions. Patients suspect for FP are undergoing 111Indium pentetreotide imaging and followed up with MRI of the involved site if positive.

Vocal fold paralysis

Bilateral vocal fold paralysis is usually idiopathic. In certain cases, paralysis may occur secondary to central neuromuscular immaturity. Paralysis may also occur because of lesions in the central nervous system, including Arnold-Chiari malformation, cerebral palsy, hydrocephalus, myelomeningocele, spina bifida, hypoxia, or hemorrhage. Birth trauma that causes excessive strain to the cervical spine may cause transient bilateral vocal fold paralysis lasting 6-9 months. Unilateral paralysis is usually idiopathic but may be secondary to peripheral nerve pathology. Birth trauma causing traction injuries to the recurrent laryngeal nerve may be responsible for a number of cases. Lesions in the mediastinum, such as tumors or vascular malformations, may cause unilateral vocal fold paralysis. Iatrogenic injury to the left recurrent laryngeal nerve can occur during surgery for cardiovascular anomalies or tracheoesophageal fistulas or during neck surgery. Clinical presentation

Laryngeal and sinonasal paragangliomas

Laryngeal paragangliomas are classified as supraglottic and infraglottic. This article defines each type of paraganglioma, discusses the clinical features and diagnoses, and covers the surgical management. This article also addresses sinonasal paragangliomas, including their clinical features, diagnosis, and treatment.

Facial nerve stimulation and postparotidectomy facial paresis.

OBJECTIVEnWe sought to evaluate the association of intraoperative facial nerve stimulation and postoperative facial nerve paresis/paralysis.nnnSTUDY DESIGN AND SETTINGnEighty-nine consecutive patients who underwent parotidectomy by a single surgeon were retrospectively analyzed for age, gender, size of tumor, tumor histology, and intraoperative use of a facial nerve stimulator.nnnRESULTSnFacial paresis developed in 22% (10 of 46) of the patients who were stimulated and 22% (5 of 23) of the nonstimulated patients. These results were not statistically significant (P = 1.0000). There was no permanent paralysis in either group. The tumor type and size and gender and age of the patient did not affect the outcome.nnnCONCLUSIONnThere was no difference in the incidence of postoperative facial nerve paresis or paralysis between the stimulated and nonstimulated patients. Routine use of a stimulator is not necessary during parotid surgery because its use does not prevent or promote facial nerve injury.

A Comparison of Radiation-Induced and Presbylaryngeal Dysphonia

OBJECTIVE: The goal of this study was to assess voice after radiotherapy compared with patients with presbylaryngeal dysphonia. STUDY DESIGN AND SETTING: Prospective assessment of 20 patients aged 60+ years who remained free of disease longer than 1 year after radiotherapy for T1 squamous cell carcinoma and retrospective review of 46 patients aged 60+ with presbylaryngeal dysphonia, conducted at a tertiary care, academic hospital. Assessment data included videostroboscopy, spectrography, voice range profile, and Voice Handicap Index. RESULTS: Eighty percent of the radiotherapy patients reported a voice disorder. Acoustic data and functional measures reflected similar limitations and abnormalities for both groups. A high incidence of glottal gap in all patients may have been associated with increased mucosal stiffness in the radiotherapy group and vocal fold atrophy in the presbylaryngeal group. CONCLUSION: Patient perception and functional outcome of voice were similar for both groups, despite differences in etiology of abnormal vocal fold vibratory behavior. SIGNIFICANCE: Radiotherapy in older individuals may yield dysphonia that is no greater than that caused by normal aging.

Hurthle Cell Neoplasms of the Thyroid

Objectives/Hypothesis Hurthle cell tumors are a variant of follicular cell neoplasms. The purpose of the study was to determine the reliability of intraoperative frozen‐section analysis for diagnosing Hurthle cell carcinoma and Hurthle cell neoplasm and to evaluate age, gender, and tumor size differences in the incidence of Hurthle cell carcinoma.

Head and Neck Squamous Cell Carcinomas Associated with Human Papillomaviruses and an Increased Incidence of Cervical Pathology

Human papillomaviruses (HPVs) have been identified in benign and cancerous epithelial lesions of the femal genital tract. They have also been identified in papillomata and cancers of the upper aerodigestive tract. This study investigates the hypothesis that lesions of the cervicovaginal area are more common in women with cancers of the head and neck region. The presence of HPV in lesions of both regions is examined. Seven female patients with cancer of the upper aerodigestive tract had DNA analysis of their carcinoma specimens. HPV type 16 was found in two of the seven (28%). Fourteen female patients with upper aerodigestive tract cancers had Papanicolaou smears to search for cytologic evidence of HPV infection, and cervicovaginal lavages to analyze DNA from exfoliated cervical cells. Five of thirteen (38%) Papanicolaou smears revealed koilocytotic atypia and three of these patients had HPV DNA types 16 or 18 identified in the cervical lavage. The incidence of cervical atypia noted is 13-fold greater than average. One patient had HPV type 16 in both her supraglottic cancer and in her cervicovaginal lavage. Evidence of HPV infection at two separate anatomic sites suggests a systemic susceptibility to HPV infection.