Paul H. Holinger

LVI Congenital Webs, Cysts, Laryngoceles and other Anomalies of the Larynx

Interest in all congenital anomalies, including those of the larynx, is increasing. This is probably due to several factors, among which are more widespread and prompt means of recognition, improvements in management, salvage of infants with other anomalies formerly considered incompatible with life who also have complicating laryngeal anomalies and the intense interest recently directed toward iatrogenic factors of congenital anomalies. The present study broadens and updates a previous review of this subject.

Etiology of bilateral abductor vocal cord paralysis: a review of 389 cases.

The etiology of 389 cases of partial or complete bilateral abductor vocal cord paralysis has been determined and classified. One hundred and forty-nine were infants and children 12 years of age and under; 240 were adults, age 13 and older. In the infants and children the paralyses were congenital in 82 cases, of which 43 were associated with other congenital anomalies, and 39 were without associated anomalies. Fifty-nine cases were considered acquired, most being secondary to underlying congenital anomalies, particularly the associated findings of meningomyelocele, Arnold-Chiari malformation, and hydrocephalus. Eight cases of paralysis in this age group were of undetermined etiology. Of the 240 adult cases of bilateral vocal cord paralysis, 138 followed thyroidectomy. Fifty-two cases were associated with various neurologic disorders, including poliomyelitis, Parkinsons disease, cerebrovascular accident, Guillain-Barré syndrome, multiple sclerosis, neoplasm, and other miscellaneous neurologic conditions. Sixteen cases were due to malignant neoplasms of the neck and mediastinum. The remaining 34 cases constitute a miscellaneous group which includes foreign bodies, bilateral neck dissection, infection, congenital lesions, trauma, and idiopathic paralyses. The characteristic symptoms of bilateral abductor vocal cord paralysis include normal or near normal phonation with inspiratory stridor which may progress to complete respiratory obstruction. These symptoms are due to the stationary but flaccid midline position of the vocal cords which places them in a phonating position, where they both obstruct the airway and produce a fairly clear voice or cry. This paradoxical combination of symptoms was frequently found to be responsible for a failure or delay in diagnosis.

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%.

Laryngocele and saccular cysts.

The symptoms, endoscopic findings, treatment and results of 46 patients with laryngoceles and saccular cysts are presented. Thirty-four were adults; 12 were infants and children under three years of age. Twenty-two adults had anterior saccular cysts, nine had lateral saccular cysts; three had laryngoceles. Ten infants and children had saccular cysts; two had laryngoceles. A laryngocele is an abnormal dilatation of the saccule which communicates with the lumen of the larynx, fills with air but on occasion may be temporarily distended with mucus; laryngoceles may be congenital or acquired. A saccular cyst is a mucus-filled dilatation of the saccule which does not communicate with the laryngeal lumen; saccular cysts are classified as lateral or anterior. Laryngoceles and saccular cysts represent abnormalities of the laryngeal saccule; a developmental spectrum exists among the normal saccule, large saccule, laryngocele and saccular cyst. The treatment of saccular cysts in infants and children is primarily repeated aspiration. In adults, symptomatic laryngoceles and large lateral saccular cysts are treated by an external approach; endoscopic aspiration and unroofing of small lateral saccular cysts is sometimes adequate and is attempted first. Anterior saccular cysts are treated by endoscopic excision biopsy. Carcinoma of the larynx may be found in association with a laryngocele or saccular cyst and must be diligently searched for by biopsies in the region of the saccular orifice. A smooth mass involving the area of the false vocal cord and aryepiglottic fold cannot be assumed to be a lateral saccular cyst; biopsies of the ventricle and saccule and deep incisional biopsies of the mass are indicated to rule out a carcinoma originating in the ventricle or saccule.

XLIV Benign Tumors of the Larynx

The extremely thorough and valuable work of New and Erich on Benign Tumors of the Larynx serves as a reference in regard to these tumors. This discussion of our own series of benign laryngeal tumors is prepared in a similar manner for statistical purposes. It consists of an analysis of 1197 patients with benign laryngeal growths that have been examined at St. Lukes and The Childrens Memorial Hospitals and at the Research and Educational Hospitals of the University of Illinois, Chicago, during the past 15 years.

LXVIII Tracheal and Bronchial Obstruction Due to Congenital Cardiovascular Anomalies

Recent achievements in thoracic surgery and advances in diagnostic techniques have aroused new interest in congenital cardiovascular anomalies. Certain of the major anomalies are now being routinely and successfully treated by surgery, and the utilization of surgical methods in this field is rapidly being broadened, If full advantage of these newer procedures is to be realized, it is imperative to recognize these developmental defects promptly and to differentiate the specific types amenable to surgery.

Revision of the clinical staging system for cancer of the larynx

The system for classification of laryngeal cancer was revised following a field study of 19 participating cancer clinics and hospitals in the United States and the T.N.M. Committee of the U.I.C.C. Study of records of 1,645 larynx cancer patients demonstrated that the best survival was experienced by patients with in‐situ carcinoma (Tis), 97%. When the tumor was limited to the region of origin (T1), survival was 94% for glottic cancers and 91% for supraglottic cases. As the tumor spread to other regions of the larynx but still confined to the larynx without fixation (T2), survival was 85%–82%; when the larynx was fixed, and tumor still confined to the larynx (T3), survival was 65%–74%, and as the tumor spread outside the larynx (T4) survival dropped to 40%–55%. When cervical lymph node metastases were not fixed, survival was ±50% (hemolateral, bilateral, or contralateral non‐fixed metastases). When the regional metastases were fixed, survival dropped to 21%. There were no survivors when the metastases were bilateral and fixed. Grouping the 4 “T”, 4 “N”, and 2 “M” categories into four stages, survival progressively decreased from 94% for Stage I, 85% for Stage II, 59% for Stage III, and 9% for Stage IV for the glottic cases. Similar survival for the supraglottic group was 91%, 82%, 49%, and 9%.

Congenital Anomalies of the Tracheobronchial Tree

Tracheal or bronchial constriction produced by membranous webs, fibrous stenoses, or deformities of cartilages can create serious problems in the newborn period. Absence of tracheal or bronchial rings at the site of a compressing vascular anomaly has been demonstrated repeatedly. Tracheal or bronchial evaginations also can produce severe respiratory obstruction. Congenital tracheal fistulas are commonly associated with esophageal atresia. Bronchial evaginations are far less common than congenital lung cysts. Bilobation of the right lung and trilobation of the left lung are the most common lobation anomalies.

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.

Studies of Etiology of Laryngeal Papilloma and an Autogenous Laryngeal Papilloma Vaccine

1. Electron microscopic studies have failed to demonstrate virus particles in papillomas of four patients with laryngeal papilloma and one patient from whom the entire base of the papilloma was evulsed and excised from the tracheal wall.2. No growth was obtained at the site of inoculation of the larynx of three female Rhesus monkeys whose true and false cords were inoculated unilaterally with 0.5 ml of a suspension made from papilloma removed from two children and one adult.3. It was not possible to duplicate work reported previously which had indicated the presence of a species-specific virus capable of producing growth of tissue cultures with regrowth after blind serial tissue culture passes.4. Blood samples were collected before and after vaccine therapy in patients with laryngeal papillomas so that in case a virus was isolated, the viral agent could be used as the antigen in a serological reaction; since the virus could not be isolated, there could be no serological evaluation of vaccine therapy.5. Th...