Symmetrical Apophyses on the Posterior Margins of the Thyroid Cartilage: A Previously Undescribed Anatomical Variation With Potential Forensic Implications.

Differential diagnosis between normal/variant anatomy and pathological/traumatic findings represents one of the main matters of investigation of the so-called forensic clinical anatomy. In the literature, many anatomical variations of the laryngeal thyroid cartilage have been reported, with potential implications in forensic pathology. They include triticeal cartilages, foramen thyroideum, asymmetry, segmentation or agenesis of the superior thyroid horns, bone connections with the hyoid bone, absence of cricothyroid facets, hypertrophy of the inferior thyroid tubercle, and asymmetries in the thyroid notch, isthmus, or length of the inferior horn. In this report, we describe a laryngeal anatomical variation never described before, consisting of 2 apophyses symmetrically arising from the posterior margins of the thyroid laminae. Postmortem computed tomography performed on the laryngeal visceral block excluded previous traumatic injuries or natural pathologies of the laryngeal cartilages, confirming the congenital origin of the finding. An "omega epiglottis" and 3 laryngeal cysts in the piriform sinuses also coexisted, suggesting the possibility of underlying common developmental mechanisms.

Laryngotracheal anomalies in children with syndromic craniosynostosis undergoing tracheostomy.

Children with syndromic craniosynostosis may present with airway anomalies. We reviewed a cohort of such individuals who underwent tracheostomy at the Great Ormond Street Hospital for Children (London, UK) between 1999 and 2012 from a prospectively collated database. A case note review was undertaken in 11 patients. We evaluated the indication for tracheostomy in these children and the presence of laryngotracheal anomalies. The most common indication for tracheostomy was upper airway obstruction refractory to medical and first-line surgical management. Laryngotracheal anomalies were detected both at diagnostic microlaryngoscopy and bronchoscopy and at the time of tracheostomy. The commonest anomaly was a tracheal cartilaginous sleeve, but we also describe the figure-of-eight trachea that, to the best of our knowledge, has not been described before in this group of patients. A mutation of a fibroblast growth factor gene was found in 71% of our patients with a laryngotracheal anomaly. We present the largest cohort of children with syndromic craniosynostosis and confirmed anatomical anomalies of the airway and uniquely describe the figure-of-eight appearance of the trachea. These findings highlight the importance of thorough airway evaluation and the special care needed in airway management for children with syndromic craniosynostosis.

The incidence of the foramen thyroideum in the South African population / Incidencia del foramen tiroideo en la población de sudáfrica

The foramen thyroideum is described as an occasional opening existing in one or both laminae of the thyroid cartilage which may or may not contain a neurovascular component. Foramen thryoideum was first described in the literature by Segond in 1847. Some authors consider its existence a structural variation rather than an anomaly, with classical texts of anatomy providing little detail when describing this foramen. This study was undertaken to investigate the incidence and characteristics of the foramen thyroideum in the South African population. A total of 80 formalin fixed cadaveric laryngeal specimens (obtained from the Department of Clinical Anatomy, University of KwaZulu-Natal, South Africa) were dissected. Larynges were dissected with the aid of a Stemi DV 4 light microscope. The incidence, location, dimensions and contents of the foramen thyroideum were recorded. The horizontal and vertical extent of each foramen was measured with a digital caliper. Six of the 80 (7.5 percent) specimens examined had distinctly identifiable foramina. Five of the six cases (4 male, 1 female) displayed bilateral foramina (6.3 percent), with one case (1 female) of a unilateral foramen (1.3 percent). Of the larynges that had bilateral foramina, a single case presented with two foramina on the same (right) thyroid lamina. A total of twelve foramina were observed. Gender distribution of foramen thyroideum was: male: right 5, left 4; female: right 2, left 1. Preceding investigators of the foramen thyroideum have rightly indicated that awareness of its presence is of paramount importance in order to preserve the structures that traverse it and also to comprehensively treat or contain laryngeal cancer.

El foramen tiroideo se describe como una apertura ocasional existente en una o ambas láminas del cartílago tiroides, la cual puede o no contener un componente neurovascular. El foramen tiroideo fue descrito por primera vez en la literatura por Segond en 1847. Algunos autores consideran su existencia como una variación estructural y no una anomalía, los textos clásicos de anatomía proporcionan pocos detalles al describir este foramen. Este estudio se realizó para investigar la incidencia y características del foramen tiroideo en la población Sudafricana. Fueron disecados 80 especímenes cadavéricos de larínge fijados con formalina (obtenidos del Departamento de Anatomía Clínica de la Universidad de KwaZulu-Natal, Sudáfrica). Las laringes fueron disecadas con la ayuda de un microscopio de luz Stemi DV 4. La incidencia, localización, dimensiones y contenido del foramen tiroideo fueron registradas. La extensión horizontal y vertical de cada foramen se midieron con un caliper digital. Seis de los 80 (7,5 por ciento) especímenes examinados tenían foramen tiroideos claramente identificables. Cinco de los seis casos (cuatro hombres y una mujer) mostraron forámenes bilaterales (6,3 por ciento), y un caso (una mujer) foramen unilateral (1,3 por ciento). De las laringes que presentaron forámenes bilaterales, un solo caso presentó dos forámenes en la misma lámina del cartílago tiroides (derecha). La distribución por sexo del foramen tiroídeo en hombres fue 5 derechos y 4 izquierdos, mientras que en mujeres 2 derechos y 1 izquierdo. Los resultados indican que el conocimiento de la presencia del foramen tiroideo es de vital importancia para preservar las estructuras que lo atraviesan y también para el tratamiento de integral o contención del cáncer de laringe.

[Surgical treatment of laryngomalacia in children]. / Leczenie operacyjne wiotkosci krtani u dzieci.

INTRODUCTION: Laryngomalacia is the most common congenital malformation of the larynx which causes stridor in newborns and infants. The stridor is inspiratory and it is first noted at birth but sometimes may not develop until 2 weeks of age. It increases in severity during crying, nursing, agitation, excitement and is made worse with head flexion or supination. Other symptoms such as supraclavicular, intraclavicular, intercostal and abdominal retractions may be associated. Boys are affected over twice as often as girls. Diagnosis of laryngomalacia is made by rigid or flexible laryngoscopy. Although this disorder is usually self-limited, in some cases the symptoms are so severe that operative intervention cannot be avoided. MATERIAL AND METHODS: Between 2002 and 2005, 13 infants were operated for severe form of laryngomalacia in the Pediatric ENT Dept in Poznan. In all patients the rigid or flexible laryngoscopy was performed to confirm the diagnosis. Then aryepiglottoplasty or epiglottoplasty were performed in all cases. It involved excision of the redundant mucosa over the arytenoid cartilages, the offending parts of he aryepiglottic folds, and trimming the lateral edges of the epiglottis, using microlaryngeal scissors and forceps. RESULTS: In all children symptoms such as: laryngeal stridor, feeding difficulties and dyspnea improved or completely resolved. In one case post-operative ventilation for several hours was required. All patients except one demonstrated significant airway improvement in the immediate postoperative period. CONCLUSIONS: Direct laryngoscopy must be performed prior to the aryepiglottoplasty to decide what amount of tissue to resect. Endoscopic aryepiglottoplasty with use of microlaryngeal instruments is an effective and safe method of the treatment of severe form of laryngomalacia. It is better to perform this procedure in general anesthesia without intubation.

Surgical repair of laryngotracheoesophageal clefts by tracheoesophagoplasty with two overlapping flaps.

We report a technique for surgical repair of laryngotracheoesophageal clefts from type II to IV through an anterior approach that involves performing a tracheoesophagoplasty with two overlapping flaps (TEP-TOF). We offer a technical description, a retrospective study, and a review of the literature. Ten children were operated on for laryngotracheoesophageal clefts of types II, III, or IV of the Benjamin and Inglis classification by the TEP-TOF procedure. After a median follow-up of 58 months (2 months to 12 years), neither complications nor recurrences were observed. All surgical details of the TEP-TOF procedure, including the approach, the kind of sutures, the method of creating the flaps, and the preoperative and postoperative management, are discussed and compared with the data found in the literature.

Anterior approach bilateral musculomucosal flaps repair for laryngotracheoesophageal clefts.

Laryngotracheoesophageal clefts (LTEC) are uncommon congenital anomalies that occur when the primitive foregut fails to separate into the esophagus and trachea. The surgical repair strategy involves separation or partition of the common tract. Reported here is the authors' experience with 2 cases of LTEC (type 3) repaired with bilateral musculomucosal flaps through the anterior wall of the trachea.

[Aortopexy as a surgical treatment method in infantile congenital tracheo-chondrohypoplasia and tracheomalacia]. / Aortopexia, mint a csecsemökori congenitalis tracheo-chondrohypoplasia és a tracheomalatia mütéti kezelése.

Congenital tracheal chondrohypoplasia and tracheomalacia have come to present a significant challenge in recent paediatric surgery. Authors shortly describe their pathology, pathophysiology, symptoms, diagnostic evaluation and outline the most frequency surgical procedures for them. The first three aortopexies in the authors' departments are described in this paper, with particular attention paid to the clinical problems of congenital tracheal chondrohypoplasia and tracheomalacia and the role of this method in surgical treatment, respectively. Aortopexy is quick, easy to carry out and atraumatic for the growing trachea. Authors want to draw attention to the fact that not every form of congenital tracheal chondrohypoplasia and tracheomalacia may be treated by conservative therapy, and that surgical treatment is recommended not only for life threatening forms, but for other severe forms as well.

Laringomalacia em criança: revisäo de 92 casos / Laryngomalacia in children: a review of 92 case-reports

Em revisäo de 356 endoscopias respiratórias rígidas realizadas em crianças do Hospital da Criança Santo Antonio, no período de março de 1989 a março de 1992, foram observadas 92 crianças com laringomalacia. Esta representou 60 por cento dos diagnósticos observados nas regiöes glótica e subglótica. As manifestaçöes clínicas que estiveram associadas significativamente com o diagnóstico de laringomalacia foram estridor , engasgo alimentar e cianose a esforços . Em somente 11 por cento dos pacientes foi necessária intervençäo cirúrgica (laringoplastia endoscópica). Em 30 por cento destes pacientes operados näo houve melhora, tendo sido necessária realizaçäo de traqueostomia

Laryngeal findings in short rib polydactyly syndrome: case report and embryological correlations.

Short Rib Polydactyly Syndrome (SRPS) is a group of rare congenital disorders characterized by polydactyly, short limbs, and short ribs. Infants with type I SRPS (Majewski syndrome) may exhibit dysgenesis of the larynx, which is manifested by epiglottic hypoplasia. Photographic documentation of laryngeal findings obtained at autopsy in an affected infant is provided. To our knowledge, such photographic documentation has not been previously published. Normal laryngeal development is reviewed, based on the Carnegie system of staging. The developmental errors leading to SRPS are thought to occur at 33 to 48 days of fetal life (Carnegie stages 15 through 19).

Congenital subglottic stenosis: the elliptical cricoid cartilage.

Various malformations of the cricoid cartilage produce congenital subglottic stenosis. The elliptical cricoid cartilage first was demonstrated histopathologically in horizontal sections of six postmortem specimens and now has been identified clinically in ten patients. The clinical diagnosis of the elliptical cricoid cartilage, suggested by anteroposterior soft tissue neck films, is confirmed at direct laryngoscopy. Delineation of the precise location, extent, and histopathology of subglottic stenosis provides the basis for rational management.

[Ventral enclosure of the thyroid cartilage by the hyoid bone. A complex inhibition abnormality of the laryngeal structure]. / Die ventrale Umfassung des Schildknorpels durch das Zungenbein. Eine komplexe Hemmungsmissbildung des Kehlkopfskelettes.

Performing laryngeal CTs we identified a "ventral enclosure of the thyroid cartilage by the hyoid bone" in 3 patients with vocal disturbances and demonstrated for the first time the morphological and clinical characteristics of this complex inhibition malformation: --persistence of the embryonal close relation between the thyroid cartilage and the hyoid bone with normal position of the total larynx --feminine configuration of the thyroid cartilage --tendency to disturbances of growth of the thyroid cartilage with effect on the endolarynx --reduced vocal ability and predisposition to vocal disturbances.

Ventral cleft of the larynx in an adult. Case report.

Congenital clefts of the larynx are rare and usually found dorsally. This case report describes a patient with a partial anterior nonfunsion, or ventral cleft, of the thyroid cartilage. This was first noted on computed tomography of the larynx used for delineation of carcinoma and was confirmed by horizontal whole mount histologic sections of the resected larynx. The thyroid cartilage suggested arrested fusion of the laminae in the middle to late embryonic period. This patient had an adult form of this rarely reported anomaly and the first, to our knowledge, detected with CT scan.

Management of arytenoid chondropathy and failed laryngoplasty in horses: 75 cases (1979-1985).

By use of endoscopy, 75 horses with respiratory noise and/or exercise intolerance were determined to have structural arytenoid cartilage abnormalities (60 primary, 11 after previous laryngeal surgery), or failed left laryngoplasty (4 horses) for laryngeal hemiplegia in which the arytenoid cartilage still appeared normal. Eighty-eight percent of the horses were either Thoroughbred (54 horses; 72%) or Standardbred (12 horses; 16%) racehorses; only 9 horses (12%) had occupations not related to racing. Seventy-six percent of the racehorses were 2 to 4 years old; all non-racehorses were greater than 4 years old. The male:female ratio was approximately 2:1. Of the horses with cartilage abnormalities, 28 had left-sided involvement, 22 had right-sided involvement, and 21 had bilateral involvement. Sixty-two arytenoidectomies were performed, 58 for cartilage abnormalities (22 left, 19 right, 17 bilateral), and 4 for failed left laryngoplasties. Overall, 45% of the Thoroughbred racehorses that returned to racing after arytenoidectomy raced successfully (50% left, 75% right, 22% bilateral); only 20% of the Standardbreds were able to race. Seventy-five percent of non-racehorses were able to return to their previous use. Many horses were retired intentionally after surgery.

Treatment of congenital cricoid stenosis.

Congenital cricoid stenosis is a rare malformation generally diagnosed at autopsy. Out of a total of fourteen cases reported by others, only five were treated successfully. Over a 10-year period, seven patients presented with congenital cricoid stenosis at the Sophia Children's Hospital in Rotterdam. On the basis of these numbers we surmise that this anomaly is less rare than is commonly thought. All seven patients were treated successfully. A new method of treatment is described, consisting of a combination of microsurgical laryngofissure and prolonged intubation with a new, low-friction, atoxic, soft, silicone rubber nasotracheal tube. The specially designed intubation material is also recommended for the treatment of iatrogenically damaged airways. The results indicate that this method constitutes a major advance not only in the treatment of cricoid stenosis but also in the treatment of damaged airways.

Elliptical cricoid cartilage: a unique type of congenital subglottic stenosis.

An elliptically shaped cricoid cartilage, a specific type of congenital subglottic stenosis, is described, and the laryngoscopic and radiographic findings in three cases are discussed. An "hourglass" deformity of the subglottic laryngeal airway on an anteroposterior airway radiograph is suggestive of this diagnosis.

Pathogenesis of protruded false vocal fold.

In ten patients with marked protrusion of the false vocal fold, the underlying structures were examined by computed tomography. The computed tomographic scan at the level of the false vocal fold consistently demonstrated a marked concavity of the thyroid ala on the side of the false-fold protrusion. The angle between the thyroid alae was significantly smaller in these patients than in normal controls. A combination of the above two deformities was considered to be responsible for the protrusion of the false vocal fold. Since all the patients were aged men, the deformity of the thyroid cartilage was presumed to be acquired, and related in some way to the aging process of the cartilage.

[Intralaryngeal struma]. / Struma intralaryngealis.

This is the first report of an intralaryngeal struma in which particular case the thyroid tissue was connected with the extralaryngeal struma because of a defect in the thyroid cartilage below the beginning of the left vocal cord. Pathogenetically speaking, it cannot be fully explained how this could develop. Hypothetically, the thyroid tissue had already invaded the larynx before the median had fused with the lateral chondrification centers of the thyroid cartilage (before the 10th-13th embryonic week); later, in the course of the struma disease, the struma developed.

Congenital cricoid stenosis.

A case of congenital cricoid stenosis in a 9-year-old girl was reported. The stenosis was confirmed by direct laryngoscopy and laryngotracheograms performed through the tracheostoma. The excess cartilaginous tissue was removed under a midline incision of the cricoid cartilage (cricoidplasty). Seventeen cases of cricoid stenosis reported since 1960 were studied and the clinical entity was discussed. On the basis of the embryology of the larynx, the mechanism of origin of this malformation was also discussed. Although cricoid stenosis was a fatal malformation before 1968, it is now a curable disease using an emergency tracheostomy and a cricoidplasty.

Congenital laryngeal stridor secondary to flaccid epiglottis, anomalous accessory cartilages and redundant aryepiglottic folds.

Most laryngeal anomalies are supraglottic and laryngomalacia is the most common. Cysts, bifid epiglottis and absence of the epiglottis are uncommon. An 18-year-old Caucasian man had long-standing stridor caused by anomalous supraglottic structures: a small floppy epiglottis, enlarged accessory cartilages and redundant aryepiglottic folds. These structures were excised and the airway was improved. The ventral portions of the fourth arches become the aryepiglottic folds and lateral segments of the epiglottis. A disturbance in this portion of the fourth arch may explain the anomaly. The cartilaginous contributions to the epiglottis were possibly isolated as accessory cartilages. Epiglottic anomalies may be associated with other anomalies, especially the digits of the hand. This patient had a short lingual frenulum and mild macroglossia.

Microcauterization in reconstructive surgery of the larynx.

The increased interest in microcauterization is related to its simplicity, accuracy, and economy. Because of its intrinic nature, microcauterization has been found to be a suitable method in the removal of cicatricial bands from the larynx, even in those patients whose larynges are difficult to expose. Some endolaryngeal suturing techniques have been developed and successfully used in combination with microcauterization in the conservative management of difficult laryngeal problems, including a congenital interarytenoid cleft. A combination of this technique has also been successfully employed in the prompt rehabilitation of a meaningful group of patients afflicted with bilateral abductor paralysis of the vocal cords.