James E. Freije

Carcinoma of the larynx in patients with gastroesophageal reflux

PURPOSE To study the relationship between gastroesophageal reflux disease (GERD) and the development of laryngeal cancer in patients who lack other accepted risk factors for the development of squamous cell carcinoma of the larynx. PATIENTS AND METHODS A retrospective review of patients either treated surgically or with radiation therapy for stage 1 or stage 2 laryngeal carcinoma with specific reference to smoking history and the presence of GERD. RESULTS We present 9 lifetime nonsmoking patients with stage 1 or 2 laryngeal carcinoma in whom GERD was clinically and/or radiographically shown. Also, 14 patients are identified who quit smoking more than 15 years before the development of laryngeal cancer and who also had evidence of GERD. CONCLUSION We propose that the development of laryngeal carcinoma in this cohort of patients who lack typical risk factors supports the notion that GERD plays a role in the etiology of carcinoma of the larynx. Because the accepted risk factors for laryngeal carcinoma such as smoking and alcohol use increase the likelihood of reflux, GERD may act as a cocarcinogen in smokers and drinkers. Of interest, the treatment of GERD can reverse the signs of chronic laryngitis and should be instituted in patients with laryngeal pathology who have GERD.

Lymphoepithelioma of the larynx

is a neoplasm most commonly seen in the nasopharynx, but it has also been reported in the nasal cavity, thymus, base of tongue, and parapharyngeal area. Lymphoepithelioma arising in the larynx is unusual; only 10 cases are reported in the medical literature. We present a lymphoepithelioma of the larynx, a review of the literature, and recommendations for management of these unusual lesions. To our knowledge, this is the first case of lymphoepithelioma of the larynx in which Epstein-Barr virus (EBV) genomes have been identified.

Comparison of Quantitative DNA Measurements and Cytomorphology in Squamous Cell Carcinomas of the Upper Aerodigestive Tract with and without Lymph Node Metastases

Cytologic smears of squamous cell carcinomas (UICC T2 through T4) from the mucosa of the upper aerodigestive tract without cervical lymph node metastases (n = 10) and with metastases (n = 20) were examined. Subsequently, the cytologic smears of the metastases (n = 20) obtained by fine-needle aspiration or following neck dissection were evaluated morphologically. Each specimen was then stained with Papanicolaou and Feulgen techniques, and quantitative DNA measurements were performed with an image analysis system. Morphologically, the primary tumors with metastases revealed an increased mean nuclear perimeter and mean nuclear area compared with tumors unassociated with metastases. On quantitative DNA measurements, the tumors with metastases had an increased DNA content, a higher 2c deviation index, and a higher DNA malignancy grade and increased number of aneuploid cells. The specimens obtained from the metastatic nodes yielded the highest values for mean DNA content, 2c deviation index, aneuploidy, and malignancy grade. The stem lines of metastasis were always nondiploid. These data indicate a positive correlation between aneuploid tumor cell clones in primary cancer and the manifestation of lymph node metastases.

Caustic and thermal epiglottitis in the adult

The presence of dysphagia, drooling, and stridor in an adult subsequent to thermal or caustic injury should alert the treating physician to the possibility of injury to the supraglottic structures with resultant epiglottitis. These adults possess many of the features seen in acute infectious epiglottitis and should be handled with the same consideration for potential upper airway obstruction. Epiglottic injuries of this type should be suspected in adults with mental disorders or communication difficulties.

Risk factors which predict persistent cancer in the abnormal larynx following definitive irradiation

Laryngeal abnormalities following definitive irradiation for carcinoma of the larynx are common. The objective of this study was to identify risk factors for persistent cancer in such patients who were found to have abnormal larynges following definitive irradiation. A retrospective evaluation of 185 consecutive patients undergoing primary irradiation for a glottic or supraglottic laryngeal squamous carcinoma treated between 1976 and 1990 at the Affiliated Hospitals of the Medical College of Wisconsin was performed. From chart review, data concerning site, stage, intent of treatment, smoking history, treatment dose, fraction size, failure patterns, and outcome were obtained. In addition, worrisome signs and symptoms including ulceration, dysphasia, odynophagia, airway distress, aphonia, blood, pain, oedema, aspiration, and pneumonia were recorded. Univariate association with failure and a persistently abnormal laryngeal examination was assessed using the Mantel-Haenszel test. The odds ratio was used to estimate relative risk associated with dichotomous risk factors. Disease-free and overall survival were estimated using Kaplan-Meier methodology. The log rank test was used to compare survival as defined by the levels of various risk factors. Two-year disease-free survival was 83% (T1 = 93%, T2 = 72%, T3/T4 = 66%). Primary failure was associated with the presence of an abnormal examination (P = 0.001), tracheotomy (P = 0.001), symptom index (P = 0.002), aphonia (P = 0.003), advanced T stage (P = 0.03), and lower total dose (P = 0.03). Of 151 patients who survived 6 months disease-free with an intact larynx, an abnormal examination was seen in those with advanced T stage (P = 0.002), supraglottic primary (P = 0.003), symptom index (P = 0.008), eventual failure at the primary site (P = 0.008), continued smoking (P = 0.01), and higher total dose (P = 0.01). The symptom index (total signs and symptoms of airway distress, aphonia, ulceration, pain, oedema, dysphagia, blood production, aspiration, pneumonia, and odynophagia) was correlated with primary failure and continued smoking. Of 37 patients with continually normal examinations, only 1 (3%) failed at the primary site. Of 102 who survived 6 months but with an abnormal examination, 22 (22%) eventually developed a primary failure. Persistently abnormal larynges are common after radiation therapy, yet not all harbour cancer. Risk factors for persistent cancer include stage, airway, total dose, and symptom index. Patients whose larynges return to normal after radiation rarely fail at the primary site.

False‐Negative Magnetic Resonance Imaging in the Evaluation of Facial Nerve Paralysis

The most common cause of unexplained unilateral facial paralysis of acute onset is Bell’s palsy. It is a diagnosis of exclusion. A high degree of suspicion for tumor should be maintained if there are 1. incomplete recovery within 6 months of onset; 2. associated tics or spasms; 3. slow onset of paralysis; 4. paralysis of isolated branches; or 5. recurrent paralysis with incomplete recovery. The evaluation of such cases frequently begins with magnetic resonance imaging (MRI) of the facial nerve. Multiple recent reports in the literature describe typical patterns of enhancement for Bell’s palsy. We present three cases of unilateral facial nerve paralysis with normal or minimal findings on MRI scans in which malignancy was eventually identified. These case demonstrate the need to maintain a high degree of clinical suspicion, the importance of scanning the parotid gland when evaluating facial paralysis, and the possible need for exploration of high-risk cases despite normal or near-normal scans.

Tracheal advancement flap for postlaryngectomy stomal stenosis

Tracheal stenosis can be a troubling consequence of laryngectomy. Some revision techniques disturb the posterior stoma site of a current or planned tracheoesophageal puncture (TEP).