Joyce A. Schild

Subglottic stenosis in infants and children.

Of 158 cases of subglottic stenosis 115 were congenital and 43 acquired. Current follow-up has been obtained in 146 (92%) which constitutes the determinate group. Although stridor was the most common presenting symptom of the congenital group, 34% presented with recurrent or prolonged episodes of croup. Tracheotomy was required in 47 of the 107 determinate cases (44%). Further management of the congenital cases was based on the experience that children outgrow this disorder; periodic dilatation may augment the natural process. Of those infants and children tracheotomized, all but five have been decannulated, and there was one death — a mortality rate of 2.1%. Acquired subglottic stenosis proved to be a more difficult management problem. Tracheotomy was necessary in 38 of the 39 determinate cases (97%). Repeated active dilatations for prolonged periods were usually required as well as endoscopic removal of granulation tissue. Of those infants and children tracheotomized, all but eight have been decannulated. There were nine deaths; five were due to unrelated underlying disease; four were attributable to complications of long-term tracheostomy. Thus, in the entire series, 85 infants and children required tracheotomy and five deaths may be attributable to long-term tracheostomy complications — a mortality rate of 5.9%.

Cartilage involvement in laryngeal carcinoma: correlation of CT and pathologic macrosection studies

Fifteen patients with laryngeal epidermoid carcinoma underwent CT of the larynx prior to surgery. Whole mount sections of the extirpated larynx cut in the horizontal plane were compared with the corresponding level of the preoperative CT sections. This study in particular was designed to evaluate the accuracy of diagnosing cartilage involvement by CT and to correlate CT findings with histologic involvement. Our results indicate that CT correlates well with anatomic location of gross cartilage involvement by the tumor; however, small macroscopic invasion of the laryngeal cartilages may be difficult to diagnose with CT. Microscopic involvement of the cartilages cannot be diagnosed with CT. Decisions regarding conservation surgery cannot be based on CT evaluation alone.

Platysma Myocutaneous Flap for Repair of Hypopharyngeal Strictures

Hypopharyngeal strictures, either isolated or in conjunction with laryngeal and esophageal strictures, can occur following lye ingestion. Extensive stricture formation requires reconstruction to create a functional funnel system that empties below the cricoid. Esophageal replacement is not a substitute for adequate hypopharyngeal reconstruction. The pectoralis major muscle is often inadequate, because it yields too much bulk and often leads to continued aspiration. The platysma myocutaneous flap for hyopharyngeal reconstruction has not been previously reported. The inferiorly based platysma myocutaneous flap was used in two of our patients with lye burns, and bilateral superiorly based flaps were used in one. All are able to eat normally and have no significant stenosis. The platysma myocutaneous flap is a relatively simple and reliable alternative that is within the capability of every head and neck surgeon.

Laryngeal changes during exercise and exercise-induced asthma

Exercise-induced asthma is defined as bronchospasm within the distal airways initiated by exercise. Whether the larynx responds to produce an exacerbation or alleviation of symptoms during an attack has never been evaluated. Thirty subjects were tested, including 15 normals and 15 with exercise-induced asthma. Laryngeal response to exercise was determined by measuring the area of the glottic aperture before, during, and after exercise. The glottis was visualized with a flexible laryngoscope and video images were recorded during monitoring of respirations. Asthma was induced in subjects by having them exercise on an ergometer for 10 minutes while breathing dry air at 10°C. Measurements were subsequently made from recorded images and relative glottic areas were compared between groups. Our data quantify the normal physiologic response of the larynx to exercise and demonstrate a substantial laryngeal contribution to asthma induced by exercise.

Laryngeal Malignancies and Computerized Tomography Correlation of Tomographic and Histopathologic Findings

We compared the anatomic structures, computerized tomographic (CT) scan images and the histopathologic findings after surgery in 15 patients with laryngeal epidermoid carcinoma. We examined the horizontal whole-mount histologic sections along with the preoperative CT and verified the preoperative impression of the soft tissue changes of preepiglottic space involvement; true cord, false cord and aryepiglottic fold invasion; or subglottic extension in all 15 patients. It was impossible to judge reliably the microscopic invasion of bone or cartilage with this method. Preoperative CT evaluation of carcinoma of the larynx was a reliable method for judging gross tumor size, though decisions regarding conservation surgery cannot be based on CT evaluation alone.

Extraluminal Foreign Bodies (Coins) in the Food and Air Passages

Four children with foreign bodies found outside the lumen of the upper food and air passages are presented. The diagnostic difficulty of such extraluminal foreign bodies and the importance of accurate localization by endoscopy and radiologic examination prior to external surgical removal are discussed.

Caustic ingestion in adult patients.

Sixteen adult patients who ingested caustic substances were seen from 1977 through 1984. All patients underwent endoscopy to determine the site and severity of burns; mild hyperemia to severe, penetrating necrosis was detected in each patient. Ten ingestions were intentional, 4 accidental, and 2 questionably accidental. Morbidity and mortality were high, especially in patients who ingested caustic materials intentionally. A protocol for treatment with steroids and antibiotics was followed in half the patients studied. Those patients who completed this regime tended to have moderately severe burns. Caustic ingestion in adults must be viewed as a problem different from that of accidental ingestion in children. Since most adult caustic ingestions are intentional, the injuries are worse, more deaths result, and more severe scars causing permanent disability are a frequent outcome.

Pharyngeal, laryngeal and tracheal injuries in the pediatric age group

In an analysis of the problem of laryngeal injuries, consideration is given to both internal and external trauma. The etiology of internal trauma consists largely of the effects of aspirated foreign bodies, burns, and prolonged intubation; screamer’s nodes caused by vocal abuse is not included in this discussi0n.l External trauma is produced by the physical violence of childhood, sports and the rapidly increasing category of automobile accidents (Table I).

Lathyrogenic Agents as Therapy for Subglottic Stenosis—A Pilot Study:

The surgical repair of subglottic stenosis (SGS) is often unsuccessful because of recurrence of the scar contracture. Over the past few years, two lathyrogenic agents (compounds that inhibit collagen cross-linking) have been shown effective in prevention of stenosis in animal models that have deep caustic esophageal burns. Since the principles of induced lathyrism have not been applied to the treatment of laryngotracheal stenosis, a pilot study using a canine model was conducted to test the efficacy of penicillamine and N-acetyl-L-cysteine in reduction of the rate of reformation of SGS. In all six animals used, a complete, 10 to 15 mm thick, mature SGS was induced experimentally, then opened with a Co2 laser. The dogs that were treated with lathyrogenic agents exhibited a lower rate of re-stenosis (one maintained patency throughout the 5 weeks of treatment) when compared to the two control dogs. Histologic sections of the subglottis in each dog revealed severe cricoid collapse, necrosis, and scarring, and thus demonstrated similarities to SGS in human beings. The two lathyrogenic agents used in this study are already approved for human use and may represent a valuable form of adjunctive therapy in the surgical management of SGS.

Evaluation of Laryngeal Calcium Deposition: A New Methodology

Despite study for over 100 years, sites and patterns of laryngeal calcification and ossification are understood incompletely. Methodologies used in the past have included radiographic imaging and histologic staining with hematoxylin and eosin. Investigation of this subject offers potential application in the correlation of laryngeal disease with loss of normal calcification patterns. A technique for the detection of calcium deposition in human larynges, formerly used only in staining bony and cartilaginous tissue of small vertebrates, is described. This technique offers the advantage of whole organ staining and provides a sensitive means of determining degree and pattern of laryngeal calcification. The results of our pilot investigation with photographic examples are presented.