Monkeypox presenting as supraglottitis in an immunocompromised patient.

We describe a young man with AIDS who presented to the ear, nose and throat team with a severe sore throat mimicking supraglottitis. He had a 3-day history of sore throat, hoarse voice, fevers and myalgia. On examination, he had cervical lymphadenopathy and profuse pus overlying his right tonsil. On flexible nasoendoscopy, this pus was seen to track down to the supraglottis, with associated mucosal ulceration. The patient was treated for supraglottitis and he improved. 24 hours postadmission, a pustule suspicious for monkeypox developed on the patient's hand. The diagnosis was confirmed by PCR testing. The patient was isolated and treated supportively and recovered fully. This case highlights that monkeypox may present with a severe sore throat without cutaneous lesions. Monkeypox is a growing public health concern . Its early symptoms are non-specific and healthcare professionals should be alert to it.

Quality assurance of radiotherapy in the ongoing EORTC 1420 "Best of" trial for early stage oropharyngeal, supraglottic and hypopharyngeal carcinoma: results of the benchmark case procedure.

INTRODUCTION: The current phase III EORTC 1420 Best-of trial (NCT02984410) compares the swallowing function after transoral surgery versus intensity modulated radiotherapy (RT) in patients with early-stage carcinoma of the oropharynx, supraglottis and hypopharynx. We report the analysis of the Benchmark Case (BC) procedures before patient recruitment with special attention to dysphagia/aspiration related structures (DARS). MATERIALS AND METHODS: Submitted RT volumes and plans from participating centers were analyzed and compared against the gold-standard expert delineations and dose distributions. Descriptive analysis of protocol deviations was conducted. Mean Sorensen-Dice similarity index (mDSI) and Hausdorff distance (mHD) were applied to evaluate the inter-observer variability (IOV). RESULTS: 65% (23/35) of the institutions needed more than one submission to achieve Quality assurance (RTQA) clearance. OAR volume delineations were the cause for rejection in 53% (40/76) of cases. IOV could be improved in 5 out of 12 OARs by more than 10 mm after resubmission (mHD). Despite this, final IOV for critical OARs in delineation remained significant among DARS by choosing an aleatory threshold of 0.7 (mDSI) and 15 mm (mHD). CONCLUSIONS: This is to our knowledge the largest BC analysis among Head and neck RTQA programs performed in the framework of a prospective trial. Benchmarking identified non-common OARs and target delineations errors as the main source of deviations and IOV could be reduced in a significant number of cases after this process. Due to the substantial resources involved with benchmarking, future benchmark analyses should assess fully the impact on patients' clinical outcome.

Chronic non-granulomatous supraglottitis of a male adolescent and its successful management with azathioprine.

Chronic non-granulomatous supraglottitis (CNGS) is a rare disorder of the supraglottic larynx, characterised by chronic supraglottic inflammation in the absence of granulomata, vasculitis, neoplasia, autoimmune disease or infective changes on histology. We present the case of a male adolescentwho attended with progressively worsening exertional dyspnoea, stridor and symptoms of obstructive sleep apnoea. Flexible nasendoscopy revealed marked supraglottic subepithelial thickening sparing the glottis and subglottis, confirmed on microlaryngoscopy. MRI of the head and neck demonstrated diffuse, homogenous supraglottic oedema. At the peak of his symptomology, the patient was admitted for further investigations and intravenous steroid therapy, and switched to prolonged oral steroids on discharge. Tracheostomy was avoided. After 3 months, he was successfully weaned from steroids to azathioprine with gradual symptomatic improvement. This case represents the first successful use of a steroid-sparing agent in the management of CNGS.

Supraglottic Squamous Cell Carcinoma: A Population-Based Study of 22,675 Cases.

OBJECTIVES/HYPOTHESIS: The authors used the Surveillance, Epidemiology, and End Results (SEER) database to analyze epidemiological features of patients presenting with supraglottic squamous cell carcinoma (SCCa) and to evaluate treatment trends and outcomes. METHODS: The SEER database was queried for patients with supraglottic SCCa from 1973 to 2013. Information on demographics; tumor size; histologic grade; American Joint Committee on Cancer (AJCC) stage; SEER local, regional, distant stage; and treatment modality were analyzed. RESULTS: There were 22,675 cases of primary supraglottic SCCa identified. The mean age at diagnosis was 62.3 years, with males accounting for 70.3% of all cases. A high percentage of patients presented with stage IV disease (44.9%). The most common treatment modality was radiotherapy (46.6%), followed by combination of surgery and radiotherapy (29.2%) and surgery alone (15.0%). Overall 5-year disease-specific survival (DSS) for all cases was 54.0%. When stratified by treatment modality, 5-year DSS was best for patients receiving surgery alone (64.2%). However, for patients with AJCC stage IV disease, survival was significantly better with combined surgery and radiotherapy (52.5%). CONCLUSION: In general, supraglottic SCCa is treated most commonly with radiotherapy, followed by surgery and radiotherapy. Patients managed surgically had better 5-year DSS when compared to patients treated by other modalities. However, when stratified by stage, patients with AJCC stage IV disease had significantly better survival with combined surgery and radiotherapy. Of patients receiving surgery, supraglottic laryngectomy was found to have a significantly better 5-year DSS when compared to both total laryngectomy and laryngectomy, not otherwise specified. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1822-1827, 2019.

Multipathogenic necrotising supraglottitis in an immunocompetent patient.

Supraglottitis is a potentially life-threatening condition. It is now uncommon due to the Haemophilus influenzae type B vaccination and is more recently caused by Streptococcus pneumoniae, S. pyogenes, H. influenzae non-type B, H. parainfluenzae, Staphylococcus aureus and Pasteurella multocida Very rarely, it can cause necrotising supraglottitis/epiglottitis, and this has been reported in immunocompromised individuals. We present a unique case of multipathogenic supraglottitis causing laryngeal fibrinoid necrosis in an immunocompetent patient. During his admission, the patient was critically unwell and required surgical intervention and tracheostomy. However, he made a full recovery with no persisting morbidity. We believe that this was owed to the aggressive antimicrobial therapy, timely surgical management of the disease process and the patient’s immunocompetency.

Adult acute supraglottitis: Analysis of 358 patients for predictors of airway intervention.

OBJECTIVES/HYPOTHESIS: Acute supraglottitis is a potentially life-threatening condition due to rapid onset upper airway obstruction. The study aimed to characterize adult acute supraglottitis patients and to recognize factors associated with an aggressive disease course. STUDY DESIGN: Retrospective chart review. METHODS: All adult acute supraglottitis patients admitted to a single academic medical center between 2000 and 2014 were included and their medical charts reviewed. The main outcome measures were airway intervention and mortality. RESULTS: Three hundred fifty-eight patients were enrolled. Mean age was 53 years (range, 16-92 years), with 62.8% males. Sore throat (79%) and dysphagia (70.9%) were the most common symptoms. Stridor (3.6%), tachypnea (5.7%), and dyspnea (6.4%) were uncommon but significantly associated with airway intervention. The epiglottis was most commonly involved (67%). Involvement of the epiglottis and aryepiglottic folds showed a trend of correlation to airway intervention. Blood glucose levels, C-reactive protein (CRP) levels, and relative neutrophilia were significantly higher in patients admitted to the intensive care unit or requiring airway intervention. Thirty-four patients (9.5%) required intensive care unit admission. Sixteen patients (4.4%) required airway intervention. Recurrent episodes of supraglottitis, seen in 19 patients, were more common in males (P = .048), and tended to have a more severe clinical course, requiring more airway interventions (P = .005) and intensive care unit admissions (P = .016). CONCLUSIONS: The typical high risk patient-a male, with dyspnea and stridor, presenting with edema of the epiglottis and aryepiglottic folds, elevated CRP, hyperglycemia, and a history of recurrent episodes-should warrant more aggressive treatment and closer observation. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:2106-2112, 2017.

Types of laryngomalacia in children: interrelationship between clinical course and comorbid conditions.

The aim of this study was to: (1) find out whether laryngomalacia (LM) types are related to clinical course; (2) which patients with LM are at higher risk of other airway malacia [tracheomalacia (TM) and/or bronchomalacia (BM)]; and (3) evaluate the prevalence of LM in our region. Patients with established LM diagnosis and complete clinical and endoscopy records were enrolled. They were classified into different LM types according to classification based on the side of supraglottic obstruction. One hundred ten children were included. The most common LM appearance was type I-58 children, followed by combine types (I + II and I + III)-38. The other airway malacia were found in 47 patients: TM in 31, BM in 10, and TM with BM in 6. Other comorbidities (cardiac, neurological, and genetic disorders) were identified in 30 children. Patients with combine types of LM differ from those with single type of LM in terms of prematurity (13 vs 31 %, p = 0.04) and higher weight on the examination day (p = 0.006). Patients with other airway malacia differ from children with isolated LM in terms of prematurity (40 vs 13 %, p = 0.008), comorbidities (38 vs 19 %, p = 0.024), and lower weight on the examination day (p = 0.014). The prevalence of clinically relevant LM was one in 2600-3100 newborns. Clinical course of LM cannot be anticipated on the basis of solely endoscopic evaluation of the larynx. Comorbidities and prematurity increase the risk of other airway malacia. The prevalence of LM is relatively high in the middle-south part of Poland.

MicroRNA expression profiles in supraglottic carcinoma.

MicroRNAs (miRNAs) are single-stranded RNA molecules which regulate gene expression at the post-transcriptional level and several miRNAs have been found to be associated with some types of cancer. We sought to identify the expression and involvement of miRNAs in supraglottic carcinoma tissues compared with normal tissues and to determine whether miRNA expression is predictive of disease. Unsupervised clustering shows that miRNA profiles can distinguish tumor from normal tissues. Analysis of miRNA contents in supraglottic carcinoma highlighted nineteen differentially expressed miRNAs, three upregulated miRNAs (miR-21, miR-19a, miR-33a) and two downregulated miRNAs (miR-206, miR-375). The microarray results of supraglottic carcinoma and related computer analysis may be beneficial for further analysis of cancer diagnosis and therapy.

Management of bleeding associated with malignant wounds.

Bleeding malignant wounds in palliative care patients can be anxiety-provoking for patients, their caregivers, and healthcare providers, and can be difficult to manage. We present the case of a 60-year-old man with a bleeding neck wound due to squamous cell carcinoma of the hypopharynx admitted to our inpatient palliative care unit. Management of bleeding included local wound care measures and psychosocial support for the patient and his wife. We review therapeutic approaches to managing bleeding malignant wounds with the aim of providing clinically useful information.

Airway management before chemoradiation for advanced head and neck cancer.

BACKGROUND: Patients with upper aerodigestive tract tumors can have development of airway compromise both before and during chemoradiotherapy (CRT). Tracheotomy is the classic method for securing a safe airway, but tumor debulking may also be used. METHODS: This was a retrospective review of locoregionally advanced tumors of the base of tongue, larynx, or hypopharynx undergoing CRT between 1995 and 2007. RESULTS: Forty-two of the 109 patients presented with signs or symptoms of airway obstruction. Of these, 28 underwent tracheotomy before CRT, and 11 had tumor debulking. Two of the 11 patients who underwent debulking required tracheotomy within 1 year after CRT for persistent edema and fibrosis. Larynx tumors were more likely to require tracheotomy or debulking than other tumors (p = .01). CONCLUSIONS: Debulking is a safe and effective alternative to tracheotomy in select patients with tumor-related airway obstruction before CRT. Patients who undergo debulking should be monitored closely for recurrence of airway compromise during and after CRT.