A rare case report of an solitary neurofibroma in postcricoid region of hypopharynx.

RATIONALE: Postcricoid neurofibroma is an extremely rare hypopharynx tumor that can be challenging in both diagnosis and treatment. This case sheds light on the possibility of treatment with transoral microsurgery before pursuing open cervical incisions. PATIENT CONCERNS: : A 43-year-old man presented with a four months history of a persistent foreign body sensation and mild dysphagia. Indirect and direct laryngoscopy at admission revealed a round and smooth submucosal mass in the postcricoid region. DIAGNOSIS: A laryngeal enhanced computed tomography and laryngoscopy suggested that the tumor located in hypopharynx, with clear boundary and slightly strengthened edge. A supporting laryngoscopy surgery was performed under general anesthesia and a biopsy confirmed solitary neurofibroma of the postcricoid region. INTERVENTIONS: The tumor was successfully resected en bloc transorally through supporting laryngoscope, and obviated the need for open cervical surgery and tracheostomy. OUTCOMES: The patient recovered well without any intraoperative or postoperative complication and was discharged from hospital 2 days after surgery. There was no recurrence after 6 months follow-up. LESSONS: Postcricoid neurofibroma is an extremely rare hypopharynx tumor that can be diagnostically challenging. To the best of our knowledge, this is the first case reported of solitary neurofibroma originating from the postcricoid region of the hypopharynx and was surgically removed with transoral surgery through supporting laryngoscope.

Changes in hypopharyngeal glands of nurse bees (Apis mellifera) induced by pollen-containing sublethal doses of the herbicide Roundup®.

Decreasing pollinator populations worldwide has generated great concern and stimulated countless studies to understand the origin of colony losses. One main cause is the indiscriminate use of different pesticides, producing subtle negative effects on bee physiology and behavior. Royal jelly synthesized in the hypopharyngeal glands is an essential protein for feeding all individuals of the hive, especially the queen. Therefore, the present study aimed to determine the effect of sublethal concentrations of Roundup® on the hypopharyngeal glands of nursing workers, including its interference with the production of royal jelly. The herbicide was found to promote changes in the cellular ultrastructure of these glands, causing early degeneration of the rough endoplasmic reticulum and morphological and structural changes in the mitochondria. No changes were noted in the amount of royal jelly produced, but additional long-term studies are necessary to determine possible qualitative changes. This is the first study to evaluate the effect of Roundup® on the royal jelly-producing glands, showing that resultant alterations in these structures can trigger damage to the development and survival of bee colonies.

A novel surgical management of hypopharyngeal branchial anomalies.

OBJECTIVE: To review our experience treating hypopharyngeal branchial anomalies utilizing an open transcervical approach that: (1) includes recurrent laryngeal nerve (RLN) monitoring and identification if needed; (2) resection of tract if present; and (3) a superiorly based sternothyroid muscle flap for closure. METHODS: A retrospective chart review was performed to identify all patients at a tertiary level children's hospital with branchial anomalies from 2005 to 2014. The clinical presentation, evaluation, treatment and outcome were analyzed for those patients with hypopharyngeal branchial anomalies. RESULTS: Forty-seven patients who underwent excision of branchial anomalies with a known origin were identified. Thirteen patients had hypopharyngeal branchial anomalies. Six of these patients were treated by the authors of this study and are the focus of this analysis. All six underwent an open transcervical procedure with a sternothyroid muscle flap closure of a piriform sinus opening over a nine year period. Definitive surgery included a microlaryngoscopy and an open transcervical approach to close a fistula between the piriform sinus and neck with recurrent laryngeal nerve monitoring or dissection. A superiorly based sternothyroid muscle flap was used to close the sinus opening. There were no recurrences, recurrent laryngeal nerve injuries or other complications from these procedures. CONCLUSIONS: This study supports complete surgical extirpation of the fistula tract using an open cervical approach, recurrent laryngeal nerve monitoring or identification, and rotational muscle flap closure to treat patients with hypopharyngeal branchial anomalies.

Endoscopic cauterization of congenital pyriform fossa sinus tracts: an 18-year experience.

IMPORTANCE: Congenital pyriform fossa sinus tracts predispose to neck masses and neck abscesses in pediatric and occasionally adult patients. Traditional management involves open excision with substantial potential morbidity. Endoscopic management allows an alternative, less morbid treatment approach. OBJECTIVE: To evaluate the long-term effectiveness of endoscopic cauterization as definitive treatment for pyriform fossa sinus tracts. DESIGN, SETTING, AND PATIENTS: Retrospective review of the medical records of 23 children (aged 7 months to 14 years) with pyriform fossa sinus tracts treated with endoscopic cauterization between 1995 and 2013 at a tertiary care children's hospital. INTERVENTION: Endoscopic electrocauterization of pyriform fossa sinus tract opening. MAIN OUTCOMES AND MEASURES: Recurrence of symptoms after endoscopic treatment. RESULTS: Twenty-one of 23 patients experienced no recurrence after their first endoscopic electrocauterization of the sinus tract. The 2 patients with recurrence experienced symptoms within 1 month of cauterization and were treated with either open excision or recauterization. Endoscopic cauterization was able to definitively treat 9 patients whose treatments with incision and drainage or open excision had failed. Mean (range) follow-up for the 15 patients with follow-up was 7.4 (0.10-14.2) years. No procedure-related morbidity was reported. CONCLUSIONS AND RELEVANCE: Endoscopic cauterization seems to be an effective and potentially permanent treatment for congenital pyriform fossa sinus tracts.

Branchial anomalies in children.

BACKGROUND: Branchial cleft anomalies are the second most common head and neck congenital lesions seen in children. Amongst the branchial cleft malformations, second cleft lesions account for 95% of the branchial anomalies. This article analyzes all the cases of branchial cleft anomalies operated on at Great Ormond Street Hospital over the past 10 years. METHODS: All children who underwent surgery for branchial cleft sinus or fistula from January 2000 to December 2010 were included in this study. RESULTS: In this series, we had 80 patients (38 female and 42 male). The age at the time of operation varied from 1 year to 14 years. Amongst this group, 15 patients had first branchial cleft anomaly, 62 had second branchial cleft anomaly and 3 had fourth branchial pouch anomaly. All the first cleft cases were operated on by a superficial parotidectomy approach with facial nerve identification. Complete excision was achieved in all these first cleft cases. In this series of first cleft anomalies, we had one complication (temporary marginal mandibular nerve weakness. In the 62 children with second branchial cleft anomalies, 50 were unilateral and 12 were bilateral. In the vast majority, the tract extended through the carotid bifurcation and extended up to pharyngeal constrictor muscles. Majority of these cases were operated on through an elliptical incision around the external opening. Complete excision was achieved in all second cleft cases except one who required a repeat excision. In this subgroup, we had two complications one patient developed a seroma and one had incomplete excision. The three patients with fourth pouch anomaly were treated with endoscopic assisted monopolar diathermy to the sinus opening with good outcome. CONCLUSION: Branchial anomalies are relatively common in children. There are three distinct types, first cleft, second cleft and fourth pouch anomaly. Correct diagnosis is essential to avoid inadequate surgery and multiple procedures. The surgical approach needs to be tailored to the type of anomaly of origin of the anomaly. Complete excision is essential for good outcomes.

Foregut duplication cyst of the hypopharynx: a rare cause of upper airway obstruction.

Foregut duplication cysts of the hypopharynx are extremely rare, and only 6 cases, all of which have been described as solid lesions and contained heterotopic gastric epithelium, could be found during our literature review. We present a unique case of a hypopharyngeal foregut duplication cyst that was grossly cystic and had no heterotopic epithelium microscopically. The present case required intubation for stridor and airway obstruction shortly after birth. Congenital laryngeal cysts can appear similar to this lesion. However, the hypopharyngeal location of a cyst is a clue for the diagnosis of duplication on endoscopic examination.

[Laser coagulation in the endoscopic management of fourth branchial pouch sinus]. / Traitement endoscopique au laser des fistules de la 4e poche endobranchiale.

OBJECTIVES: To describe a new method of treatment of the fourth branchial pouch sinuses by laser endoscopic coagulation of the fistula. MATERIAL AND METHODS: Retrospective study of two children aged 3 and 12 years with fourth branchial pouch sinuses. Both children presented recurrent cervical abscesses. The diagnosis was established on results of ultrasound, barium study, CT scan and pharyngoscopy. After recovering from infection, the definitive treatment was a laser diode cauterization of the fistulous route and its pharyngeal opening. RESULTS: Outcome was rapidly favorable in both children without complications or recurrence. DISCUSSION: These two cases and other reports in the literature confirm the role of endoscopic management for the treatment of the fourth branchial pouch sinus. Laser treatment is especially useful because of its convenience, its harmlessness and its reliability. CONCLUSION: Fourth branchial pouch sinuses are rare. Surgery, which can be difficult and not without risks, is the generally accepted treatment. This new laser method combines ease of treatment and efficacy.

An anatomical protrusion exists on the posterior hypopharyngeal wall in some elderly cadavers.

Dysfunction of the cricopharyngeus is a common cause for dysphagia in the elderly and results in the appearance of the cricopharyngeal bar on a barium swallow radiological examination. However, manometrically normal relaxation of the cricopharyngeus has been observed in patients with a permanent cricopharyngeal bar, which implies that some structural changes may occur in the pharyngoesophageal wall. The aim of this study was to examine the macro-microscopic morphological features in the posterior hypopharyngeal wall of elderly human cadavers. Using dissection, histology, and E12 sheet plastination methods, we examined 31 human cadavers (15 females and 16 males; age 60-97 years with a mean of 77 years). We found that about one-third of the cadavers (29%, 9 out of 31) had an anatomical cricopharyngeal protrusion on the posterior hypopharyngeal wall. The protrusion presented two different appearances: a transverse ridge (2 females and 4 males, age 60-91 years) and a tongue-like fold (1 female and 2 males, age 71-86 years). The existence of the anatomical protrusion in the elderly cadaver suggests that such a structural change may become a physical barrier to affect the normal deglutition in the living elderly and should be carefully considered when interpreting radiological and manometrical examinations and with the management of dysphagia.

Assessment of obstructive apnea by using polysomnography and surgical treatment in patients with Beckwith-Wiedemann syndrome.

PURPOSE: Obstructive apnea is sometimes seen in patients with Beckwith-Wiedemann syndrome. The cause of apnea is not limited to macroglossia, and the surgical indication for obstructive apnea has not yet been established. The authors performed polysomnography for the assessment of apnea. METHOD: Overnight polysomnograms were obtained in 2 patients who developed obstructive apnea after 1-stage repair for omphalocele. CASE 1: Apnea index (AI), defined as apneic events per hour, indicated 17.3, and SpO2 below 95% occupied 80% of the total sleep time. Computed tomography and magnetic resonance imaging indicated obstruction of the airway between macroglossia and the hypopharynx. Central tongue resection and the division of the frenulum linguae for associated ankyloglossia were performed 97 days after birth. One month after surgery, apneic events disappeared and SpO2 below 95% occupied only 1% of the total sleep time. CASE 2: Obstructive AI indicated 28.1. Division of the frenulum linguae and anterior glossopexy were performed 55 days after birth. Postoperative polysomnogram indicated a marked reduction of AI. CONCLUSIONS: These results indicated that polysomnography was useful for evaluating obstructive apnea and that advancement of the tongue by division of the frenulum linguae may be recommended for the treatment of obstructive apnea in patients with Beckwith-Wiedemann syndrome.

Magnetic resonance imaging in simple snoring and obstructive sleep apnea-hypopnea syndrome.

PURPOSE: Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) is a condition characterised by periodic cessation of breathing during sleep, associated with Upper Air-Digestive Ways (UADW) morphologic abnormalities that can be detected, in awake patients, by using various imaging techniques. The purpose of this study is to determine the usefulness of MR imaging and new original morphometrical measurements that we are proposing in patients with Sleep Obstructive Breathing Disordered (SOBD). MATERIALS AND METHODS: We studied 70 patients (52 with OSAHS and 18 snoring without OSAHS) using 1.5T and 0.5T MR imagers with neck and head coils and T1-DP-T2-weighted SE sequences. During the procedure, the patients were awake and with tidal breathing. We also evaluated sagittal pharyngeal diameters at different levels; the length and maximum width of soft palate; the distance between the hyoid bone and the C2C3-Me line (ideally joining the geometrical centre of the C2-C3 intervertebral space to the lower point of mandibular symphysis) measured on the perpendicular; the angle resulting from the longitudinal axis of the cervical spine and the epiglottis axis (alpha); the slope angle of the tongue -- resulting from the longitudinal axis of the cervical spine and the longitudinal axis of the tongue (beta). We used sagittal, coronal and axial sections of the head and neck. RESULTS: In OSAHS patients, pharynx calibre medium sizes were reduced compared with simple snoring patients. Only in OSAHS patients (not in simple snorers without OSAHS) we observed: 16 patients with narrowing sites = or <3 mm. On axial images we observed three different narrowing patterns: rounded, with greater anterior-posterior axis; with greater axis in lateral direction. In OSAHS patients we also observed, on average, increase of the distance between the hyoid bone (Hmr point) and the line C2C3-Me; increase in the angle resulting between cervical rachis and epiglottis (alpha); reduction of sloping angle of the tongue (beta). CONCLUSIONS: MR imaging, together with the morphometrical measurements we are proposing, is useful to evaluate UADW in SOBD. In particular, we noted that increase of the distance between the hyoid bone (Hmr point) and the line C2C3-Me (due to lowering of the hyoid bone), increase in the angle resulting between the cervical rachis and the epiglottis (alpha) and the reduction of the sloping angle of the tongue (beta), are highly specific and sensitive indexes in OSAHS. There are different levels and findings of narrowing in OSAHS and their identification is very important for a surgical approach: the uvulo-palato-pharyngoplasty (UPPP) has a higher success rate in patients with obstruction at retro-palatopharynx site, but it is associated with no (or poor) results in hypopharyngeal obstruction.

Pyriform sinus malformations: a cadaveric representation.

BACKGROUND/PURPOSE: The most important aspects in management of pyriform sinus malformations are awareness of the diagnosis, familiarity with the clinical manifestations, and complete surgical excision of the entire tract. Pyriform sinus anomalies are the least common branchial apparatus malformations and present anatomically as sinus tracts with or without cystic dilatation. The clinical presentations can include lateral neck mass, thyroid abscess, suppurative thyroiditis, retropharyngeal abscess, neonatal airway obstruction, and even carcinoma. Recurrent symptoms after surgery suggest incomplete identification and excision of the tract. METHODS: Cadaveric dissections were performed to show both the proposed embryologic course and clinical manifestations of third and fourth branchial apparatus pyriform sinus anomalies. RESULTS: Illustrations and digital camera images of the cadaveric models are presented to explain the course of pyriform sinus fistula tracts. CONCLUSIONS: The authors discuss 3 case presentations of pyriform sinus anomalies with emphasis on their proposed embryologic origin and anatomic basis for surgical management. Surgical excision is the mainstay of therapy. Understanding the embryologic basis for pyriform sinus malformations aids in recognition of the diagnosis despite the myriad of clinical presentations. Laryngoscopy with sinus cannulation facilitates removal of the entire sinus tract with preservation of the recurrent and superior laryngeal nerves.

Sonographic discovery of a pharyngocele.

Cervical sonography was performed in a 25-year-old man who was referred to our department because of the recent appearance of a left anterolateral cervical mass. This mass had the sonographic properties of air; it communicated with and extended the piriform sinus as well as deformed the left lamina of the thyroid cartilage. A preliminary diagnosis of left pharyngocele was confirmed by CT. To our knowledge, this is the first sonographic description of such an abnormality.

Occult congenital pyriform sinus fistula causing recurrent left lower neck abscess.

BACKGROUND: Congenital pyriform sinus fistula (CPSF) is a rare branchial pouch anomaly; it has the characteristic of left-sided predominance and is not always detected until complications such as neck abscess or acute suppurative thyroiditis resulted. METHOD: Seven sequential cases of CPSF, including five adults and two children, causing recurrent left lower neck abscess were reported. All of these patients had past histories of misdiagnosis: the intervals from the onset of symptoms to correct diagnosis ranged from 3 years to 34 years with an average of 20 years. RESULTS: After barium swallow study and direct laryngoscopic examination in the quiescent stage of infection, the CPSFs of these seven patients were successfully excised with or without catheter guide. CONCLUSION: The key to diagnosis of CPSF is a high index of suspicion by the clinician. CPSF should be considered in the differential diagnosis of a neck abscess, especially if it is recurrent and left-sided.

Recurrent left cervical abscess secondary to persistent pyriform sinus fistula.

Congenital pyriform sinus fistula is a rare defect arising from the failure of obliteration of the third or fourth pharyngeal pouch remnant. It is a recognized potential cause of acute suppurative thyroiditis.

Topographic evaluation of lateral hypopharyngeal pouches using electron beam tomography.

BACKGROUND: To evaluate the exact topography of lateral hypopharyngeal pouches using electron beam tomography. METHODS: Seventeen patients, nine female, eight male, aged 28-72 years, who showed lateral hypopharyngeal pouches in the videofluorographic swallowing examination were studied using electron beam tomography. Upon swallowing a 20-ml bolus of water, the region of the thyrohyoid membrane was scanned 20 times per level. Scan parameters: single slice cine mode (exposure time 100 ms, slice thickness 3 mm, 620 mA, 130 KV). RESULTS: The lateral hypopharyngeal pouches appeared air-filled in the posterior aspect of the thyrohyoid membrane closely attached to the upper horn of the thyroid cartilage, just below the hyoid bone. CONCLUSIONS: With electron beam tomography it was possible to define the topographic location of the pouches more accurately, compared with the prior assumption of position.

[Recurrent thyroid abscess in children and malformations of the pyriform sinus]. / Abcès thyroïdiens récidivants de l'enfant et malformations du sinus piriforme.

Recurrent "abscesses" occurring in the thyroid area in children are due to branchial anomalies. Their origin is located close to the oesophageal inlet at the apex of the lateral hypopharyngeal process: the pyriform sinus. The key for the diagnosis comes from laryngohypopharyngoscopy. The true original anomaly is a controversial topic: the persistence of a canal originating from the 3rd or 4th branchial pouch. Anyhow, these anomalies sometimes build tracts or cysts in the deeper parts of the neck, down to the supraclavicular or thoracic areas. Most often, they are limited to the soft tissues surrounding the left thyroid lobe. In these cases, no cyst wall can be found. The 3 cases reported here allow us to ascertain that a pharyngeal infection is the trigger for the neck abscess. Furthermore, a mucosal opening can be the only found anomaly. After recovery from the infectious process, these anomalies have to be treated by a mucosal suture of the pyriform sinus. The recurrent laryngeal nerve should be first discovered and the removal of a small piece of cartilage can be required. If these diagnostic and therapeutic procedures are used at the first infectious episode, they may prevent the occurrence of repeated thyroid "abscesses" in children.

Laryngotracheoesophageal clefts.

This article reviews laryngeal cleft anomalies from the Laryngeal Development Laboratory at Children's Memorial Hospital in Chicago and includes a discussion of the classification of laryngotracheoesophageal clefts based on previous work and the information presented herein. Of the 115 laryngeal specimens obtained between 1975 and 1995, 11 have laryngeal cleft anomalies. Eight have a submucous laryngeal cleft. There is 1 laryngotracheoesophageal cleft, type II (partial cricoid cleft); and there are 2 laryngotracheoesophageal clefts, type III (complete cricoid cleft). The histopathologic findings are presented in detail and the literature is reviewed. Photomicrographs and drawings illustrate the pathology and classification. Clinical presentation, diagnosis, evaluation, and management are discussed, as is the embryology.

Pneumopericardium associated with high-frequency jet ventilation during laser surgery of the hypopharynx in a child.

A case of pneumopericardium, without concomitant pneumothorax, resulting from high frequency jet ventilation during laser surgery of the hypopharynx is described. The patient, a four-year-old boy, suffered cardiac arrest as a consequence of the incident. The pneumopericardium was likely to have been caused by obstruction to the expiratory flow during surgery. Other possible explanations for the incident are discussed.