Seymour R. Cohen

Five-Year Retrospective Study with Special Reference to Management

The charts of 143 patients with foreign bodies in the larynx and tracheobronchial tree who were admitted to the Childrens Hospital of Los Angeles during the period 1973 to 1978 were reviewed. Of these children 84 were male and 59 were female. One hundred were private patients and forty-three were clinic patients. Of these foreign bodies 60 were nut meat which is by far the most common foreign body of the tracheobronchial tree. All foreign bodies were successfully removed. One hundred twenty-six were discharged within the first 24 hours after admission and treatment. Fifty-one or 36% of these patients were discharged on the same day after the foreign body was removed. Sixty-two of the foreign bodies were in the left bronchial tree, while 55 were in the right bronchial tree. One hundred thirty-eight were endoscoped under general anesthesia using the apneic technique and five patients were treated with oxygen standby only because of severe respiratory obstruction. A detailed description of the use of apneic technique with profound muscle relaxation, the avoidance of preoperative medication and the team approach to ventilating the patients are all described. The advantage of general anesthesia, and the potential intraoperative and postoperative problems are reviewed. Of the total number of cases 13 % were between 4 and 11 months of age, 44% were between 12 and 23 months of age and 57% were over 23 months of age.

Laryngeal Paralysis in Children A Long-Term Retrospective Study

The charts of 100 children with laryngeal paralysis were reviewed. The patients in this study had either unilateral or bilateral abductor vocal cord paralysis. The literature and pathophysiology are reviewed. A statistical analysis of each group of patients according to etiology is reported. The follow-up, progress and recovery are detailed. The need for observation and conservative therapy is reinforced by the tendency for spontaneous recovery. Suggestions regarding treatment are given.

Retropharyngeal abscess in children: A retrospective and historical analysis

The charts of 65 pediatric patients with the diagnosis of retropharyngeal abscess were reviewed. These represented a 36‐year experience with the disease. The findings were compared with those documented at the turn of the century and were also compared with findings over the last four decades. The data suggests that retropharyngeal abscess may be occurring later in childhood and may not always be preceded by a major detectable infection. Classic diagnostic findings of retropharyngeal bulge and neck stiffness were present in less than half of the patients. Gram‐negative and anaerobic organisms are being documented on culture more frequently than in the past. We theorize that liberal use of oral antibiotics prior to admission may have brought about these changes.

Papilloma of the larynx and tracheobronchial tree in children. A retrospective study.

One hundred and forty cases of papilloma of the larynx and tracheobronchial tree are documented in the records of the Childrens Hospital of Los Angeles. The records of 90 patients were available and were reviewed intensively. The method of direct laryngoscopy with general anesthesia using apneic technique in most patients and intubation in some was an adequate method of treating patients with laryngeal papillomata. A general anesthetic was never used where obstruction was severe and the airway could not be controlled. The low incidence of papilloma of the tracheobronchial tree and an absence of parenchymal lung seeding in this series is attributed to the avoidance of a tracheotomy and fewer intubation anesthetics thus avoiding trauma to the trachea and bronchi. The immediate removal of the tracheotomy tube seems an alternative if the surgical procedure had been performed. In the patients in this series decannulation was accomplished in a very short period of time. The establishment of an airway seems to be a priority in the treatment of this disease and this can be accomplished by repeated endoscopic procedures rather than tracheotomy. Statistics are given, and prognosis based on the type of lesion and histopathology is documented.

Tracheostenosis and bronchial abnormalities associated with pulmonary artery sling.

Three patients with aberrant left pulmonary artery (sling artery) are reported to illustrate associated tracheobronchial abnormalities. The clinical picture was that of severe episodic or progressive respiratory distress without dysphagia in early infancy. Striking narrowing of the trachea by complete “ring cartilages,” unrelated to compression by the abnormal pulmonary artery, was present. Tracheotomy and intubation failed to relieve the obstruction. In one patient the bronchi and bronchial segmentation pattern were normal, but in the other two patients, bronchial abnormalities included wide irregular cartilages in the main bronchi, forming more complete rings than is normal. In both, the right main bronchus was relatively longer than normal, and the bronchus intermedius showed poor cartilage ring formation and was relatively short compared to the main bronchus. This discrepancy did not appear to be due to distal displacement of the right upper lobe bronchus. In these two patients the left main bronchus was relatively short and wide with reduced number of cartilage rings (five-six vs usual normal number of nine), so that the right and left main bronchi were almost of equal length. However, the branch patterns of the lobar bronchi were within normal range. Bronchoscopy seems essential to demonstrate such ring tracheal cartilages (absence of the pars membranacea of the trachea), which when found should alert the examiner to the possible presence of an abnormal left pulmonary artery. Since surgical correction of tracheal stenosis of this type is not possible at present, the ultimate prognosis of patients with sling artery may depend more on the severity of the tracheal anomaly rather than on success of surgical correction of the abnormal left pulmonary arterial course. Although aberrant (sling) left pulmonary artery can occur in patients without respiratory tract symptoms, tracheal stenosis due to ring tracheal cartilages occurs in a significant fraction of patients with this arterial anomaly. Bronchoscopic study of the trachea, and possibly air or contrast bronchography of right and left main bronchi, can be of aid in diagnosis of this complex.

Cleft Larynx: A Report of Seven Cases

The purpose of this paper is to familiarize the otolaryngologist with a difficult and frequently missed anomaly. It is hoped that this will increase the number of successfully managed patients with this affliction. Of the seven herein reported cases, four were posterior clefts limited to the cricoid lamina. Three were more extensive laryngotracheoesophageal clefts. Seven cases are thus added to the approximately 30 cases reported in the world literature. The limited cricoid lamina defect can only be diagnosed by endoscopic examination, and is treated medically. Feedings must be given by gastrostomy only. A tracheotomy is indicated only when oral secretions are aspirated into the tracheobronchial tree. The more extensive laryngotracheoesophageal cleft requires surgical repair through a lateral pharyngotomy approach. When the cleft is extensive and extends into the chest, surgery must include a thoracic approach. The occurrence of cleft larynx in association with tracheoesophageal fistulae, with or without atresia, may be more frequent than generally realized. A search should be made for this anomaly in patients who aspirate after atresia repair has been accomplished, before attributing this symptom to severe stricture formation, or recurrence of the fistula. The problem of aspiration in posterior cleft larynx is due to the lateral and posterior displacement of the arytenoids. This malposition is due to the absence or deficiency of the interarytenoidius muscle so that the posticus muscle is unopposed. The term “posterior cleft larynx” should be used only where the defect is limited to the cricoid lamina, while laryngotracheoesophageal cleft should be applied to the more extensive defect.

Endoscopy and Tracheotomy in the Neonatal Period A 10-Year Review 1967–1976

The charts of 124 patients who underwent endoscopy as neonates during the period from 1967 to 1976 were reviewed. Twenty-nine of these patients (23.4%) had tracheotomies performed during the first month of life; analysis of this group also is included. Three hundred and ninety-two otolaryngological procedures were performed and included direct laryngoscopy (175), bronchoscopy (91), esophagoscopy (37), tracheotomy (29), bronchial lavage (14), change of tracheotomy tube (14), esophageal dilatation (13), incision and drainage of cyst (14), removal of tracheal granuloma (3), laryngeal dilatation (1), and bronchial dilatation (1). Two hundred and forty-nine lesions were found of which 146 were laryngeal, 44 tracheobronchial, 33 esophageal, 16 craniofacial, and 10 were orohypopharyngeal. Procedures were performed under general anesthesia and no anesthetic complications occurred. Surgical complications in the neonatal period were few and never life-threatening. In the nontracheotomized group two complications were found; 38% of this group was discharged within one day of endoscopy. In the tracheotomized group eight complications occurred; none were fatal. In many cases endoscopy proved to be essential in making the specific diagnosis.

Use of Botulinum Toxin to Lateralize True Vocal Cords: A Biochemical Method to Relieve Bilateral Abductor Vocal Cord Paralysis

Using the mongrel dog as an animal model, we studied the effectiveness of botulinum toxin (Oculinum) to lateralize the true vocal cord. This experiment was undertaken in order to determine whether the toxin can improve the airway in subjects with bilateral abductor vocal cord paralysis. The toxin was injected into the cricothyroid muscle to block neuromuscular transmission at the motor end-plate. Paralysis of the cricothyroid muscle was achieved and documented by electromyography and videotaped endoscopy. Paralysis of the cricothyroid muscle decreases the tension of the true vocal cord and allows the cord to take a more lateral position. In this preliminary report, the literature is reviewed, the effect of and action of the toxin are discussed, and the results of the experimental protocol, establishment of dose-response curves, and techniques of injection are presented. Preliminary data suggest that there is an increase in the airway by lateralizing the true vocal cord with this biologic substance, and that this method may have many applications in clinical medicine for the otolaryngologist-head and neck surgeon.

Malignant Transformation of Tracheobronchial Juvenile Papillomatosis without Prior Radiotherapy

Squamous cell carcinoma of the trachea and bronchi developed in a 19-year-old male with recurrent laryngeal papillomata since age four, who had received no prior radiotherapy, but who was tracheotomized for obstructive laryngeal papillomata. Treatment with intravenous cytosine arabinoside, “moderate dose” methotrexate, topical 5-fluorouracil and irradiation failed to alter tumor growth, and the patient succumbed to recurrent arterial tumor emboli.

Botulinum Toxin for Relief of Bilateral Abductor Paralysis of the Larynx: Histologic Study in an Animal Model:

We previously reported the effectiveness of botulinum toxin injections in the cricothyroid muscle under electromyographic guidance for lateralization of the true vocal cord in the mongrel dog. These additional experiments were performed to substantiate the effectiveness of botulinum toxin injections in laryngeal muscle to overcome airway obstruction produced by bilateral abductor vocal cord paralysis. A predetermined aliquot of the toxin was injected into the cricothyroid muscle of ten dogs, the duration of its effectiveness was noted, and repeated injections were given the animals. Biopsies of the injected muscles were obtained in three of the animals for routine histologic and electron microscopic studies. The effects of the toxin were recorded by cinelaryngoscopy and videotape documentation. In all the dogs, the true vocal cord was lateralized effectively and there was no morbidity, dysphagia, aspiration, or deaths. This study also confirms that the effects of the toxin in the canine larynx are spontaneously reversed and that multiple injections do not cause irreparable damage to the laryngeal muscles.