Presence of human papillomavirus type 16 related sequences in verrucous carcinoma of the larynx.

Verrucous carcinoma of the larynx clinically resembles laryngeal papilloma in that both are wart-like masses on the vocal cords and may be characterized by multifocality and recurrence. Human papillomavirus (HPV) infection is an etiological factor in laryngeal papilloma, and recent evidence implicates HPV in squamous neoplasias. To determine whether HPV is also associated with verrucous carcinoma of the larynx, we analyzed tissue specimens from six patients with verrucous carcinoma of the larynx by Southern and DNA dot blot hybridization for HPV DNA. From three patients, specimens of normal laryngeal epithelium were also studied. All tissues showed evidence of HPV sequences related but not identical to HPV-16. They were negative for HPV-11. In contrast, four squamous cell carcinomas of the larynx and three normal laryngeal tissues were negative for HPV DNA. Histological sections of the six verrucous lesions were found to contain koilocytosis. Immunoperoxidase staining for HPV capsid antigens was negative in all these cases. The consistent and specific association of HPV with the verrucous carcinomas in this report suggests the possibility of a pathogenic involvement.

Supraglottic hemangioma during pregnancy.

A 37-year-old woman, gravida 10, para 1-0-8-1, presented in her second trimester of pregnancy with complaints of frequent sore throats, change in voice quality, and recumbent dyspnea. These symptoms were noted initially during her previous pregnancy, and resolved after delivery. She was found to have a supraglottic hemangioma which occluded 40% of her upper airway. This lesion was noted to dramatically involute beginning at 36 weeks' gestation. The supraglottic hemangioma is a very rare cause of dyspnea in pregnancy. Its growth during pregnancy and regression postpartum is possibly related to the effects of estrogen and progesterone.

Congenital subglottic hemangiomas: a treatment update.

Congenital subglottic hemangiomas are rare lesions associated with a significant degree of morbidity and mortality. Although various methods of treatment have been proposed, no one single modality has yet been shown to be uniformly effective in treating this life-threatening condition. Amongst the myriad of suggested treatments, the carbon dioxide laser, as originally proposed by Healy, et al., appears to have the highest degree of success with the lowest incidence of complications. The purpose of this paper is to review a large experience at a single institution with the use of the carbon dioxide laser for treatment of congenital subglottic hemangiomas.

Prostatic and laryngeal malignancies: common or uncommon multiple occurrence?

The presence of multiple primary malignancies involving the head and neck has been well documented. The majority of second primaries appear within the respiratory system. Few reports exist describing multiple primary malignancies involving the larynx and the prostate. This paper reports on four cases of primary laryngeal and prostatic neoplasms. Physical findings and laboratory work-up necessary for diagnosis of these lesions are reviewed. The dilemma of the proper therapeutic course based on the histological grading and pathological staging is presented. Suggestions for treatment based on the prognosis of the disease that is present are offered.

Congenital laryngeal saccular cyst of the newborn.

Congenital laryngeal saccular cysts of the newborn frequently cause severe dyspnea and upper respiratory tract obstruction. When confronted with this emergency situation necessary therapeutic action may consist of intubation, puncture or incision to reduce the volume of the cyst or tracheotomy. The CO2 laser was effectively used not only to incise the supraglottic saccular cyst but also to vaporize the lining.

Experimental results of cancellous autografts and frozen allografts transplanted into the canine frontal sinus.

Autograft and frozen allograft cancellous bone were each placed into one of the canine frontal sinus cavities of eight animals and analyzed by radiographic and histologic methods after one year. Complete and equal bony obliteration was demonstrated. Thus no advantage was seen in using an autograft over a frozen allograft in obliterating the frontal sinus cavity.

Endolaryngeal jet ventilation: a 10-year review.

Jet ventilation for microsurgery of the larynx has been in common use at our institution since 1978. There were 942 cases performed, with ages ranging from 7 days to 90 years. A specially modified laryngoscope with multiple ports into which a 14- or 16-gauge ventilation needle can be advanced just distal to the vocal cords simplifies this form of anesthesia and ventilation. Jet ventilation has been advocated in place of conventional ventilation methods during carbon dioxide laser surgery because it eliminates the potential fire hazard of the endotracheal tube and allows superior visibility of the vocal cords. Despite these advantages, it is still not in common use. We will review the airway mechanics and special anesthesia considerations that make jet ventilation a safe and time-proven technique.

Laryngeal papillomatosis: clinical, histopathologic and molecular studies.

The clinical course and pathology of 57 patients with laryngeal papillomatosis were reviewed. Tissues from 26 patients were analyzed for human papillomavirus (HPV) DNA by Southern blot hybridization. Histopathologic evaluation of the papillomas showed no correlation with age of onset or clinical pattern of remission and recurrence. The pathology was characterized by abnormal squamous maturation with parakeratosis, retardation of superficial cell maturation, papillomatosis, and basal hyperplasia. HPV DNA was present in all lesions, with 92% containing either HPV-6 or 11. Latent HPV DNA was detected in clinically uninvolved tissues of 11 of 14 (78.5%) patients studied. There was no correlation between HPV type, histopathology and/or clinical pattern. Despite homogeneity of pathology, the clinical expression of laryngeal HPV infection varied widely. A mechanism for the pathogenesis of laryngeal papillomatosis, based on the concept of maturational arrest, is proposed.

Carcinoma in situ of the glottic larynx.

Carcinoma in situ (CIS) is part of the histopathologic spectrum of laryngeal disorders where invasive squamous cell carcinoma is the endpoint of cellular disarray. Few reports consider prognostic indicators that predict which lesions become invasive. Forty-one patients with CIS of the glottic larynx were analyzed for risk factors that would predict invasive cancer. Anterior commissure involvement by CIS resulted in 92% conversion to invasive squamous cell cancer compared to 17% of lesions limited to the mobile fold. Epidermal growth factor receptors were also analyzed and were found not to be helpful in predicting invasion. Lesions of the mobile fold should be removed endoscopically and the patient should be observed closely for recurrence. Anterior commissure involvement that is inaccessible to complete laser ablation should be radiated, and the patient should be observed carefully.

Cervical thymic cyst: case report and review of literature.

An unusual case of a cervical thymic cyst in a 4-year-old boy is presented. The embryology, histopathology, and clinical presentation is discussed. This entity should be included in the differential diagnosis of cystic neck masses in the pediatric age group.

Necrotizing fasciitis as a lethal complication of peritonsillar abscess.

Abscesses of the peritonsillar region rarely lead to serious complications. Incision and drainage, antibiotic therapy, and subsequent tonsillectomy is the accepted method of treatment. Two cases of fatal necrotizing fasciitis following peritonsillar abscess are presented. The entity of necrotizing fasciitis in the head and neck is discussed with respect to its presentation, diagnosis, and treatment.

Qualitative and morphometric evaluation of vocal cord lesions produced by the carbon dioxide laser.

The canine larynx was studied to obtain qualitative and quantitative data accurately defining the destructive effects of the carbon dioxide laser on epithelial tissue by administering doses of varied energy to the dorsal surface of the vocal cords. Resultant lesions subsequently were analyzed by light, transmission, and scanning microscopy. Three major morphologic patterns of vocal cord lesions were observed: 1. cup shape, 2. doughnut shape and, 3. complex star shape. The patterns produced in the laryngeal tissue reflect the operative mode (energy distribution within the focused spot of energy) of the laser at the time of surgery. The mode resulting in the doughnut shaped pattern (energy distribution around the periphery of the spot) produced deepest lesions, with minimal thermal conduction laterally, whereas the mode resulting in the cup-shaped pattern (energy distribution uniform throughout the spot) produced at comparable doses shallower lesions with larger diameter. Too few star-shaped patterns were observed to permit meaningful morphometric analysis.

Clinical effects of alpha-interferon dose variation on laryngeal papillomas.

Achieving optimal clinical control of recurrent respiratory papillomatosis with prolonged treatment with human leukocyte (alpha) interferon appears to be dose-related and often requires individualized dosage elevation. Six of eight patients in this study needed a maximum dose of 18 x 10(6) IU/week for part of the therapy period to achieve better disease control. The strong correlation found between dosage and response suggests that it is the interferon causing the effect on disease expression, not just the unpredictable nature of the disease. An effect on papilloma growth was observed in all patients during IFN therapy. Three patients were able to be tapered off IFN with only minimal recurrence seen in one patient. No toxic side effects were observed.

Microbial adherence to and disinfection of laryngoscopes used in office practice.

This study reports the appropriate disinfection methods for flexible and rigid laryngoscopes when used in an outpatient setting. This investigation presents evidence that an appreciable number of laryngoscopes are contaminated during use. A brief tap water rinse serves to eliminate gross soil of host origin known to interfere with disinfectant efficacy. Disinfection with 3.2% glutaraldehyde (Cidexplus) for 10 minutes effectively eliminated microbial contaminants. Since potentially harmful microorganisms were included among the more than 100 isolates during our baseline experiments, the need to eliminate bacteria, viruses, fungi, and protozoa from laryngoscopes is obvious and can be attained readily.

Mucin impaction tumor of the paranasal sinuses: a new clinical entity?

A variety of uncommon benign lesions occur in the paranasal sinuses and have been reported to masquerade as carcinomas. Nearly all of such cases have been limited to the frontal, sphenoid, and ethmoid sinuses with an isolated report of maxillary sinus involvement. The classic roentgenologic picture is that of bony destruction. Heretofore described destructive lesions of the maxillary sinus include the mucocele, mucous retention cyst, pseudocyst, pyocele and cholesteatoma. This report deals with a previously undescribed entity, the mucin impaction tumor located in a septate maxillary sinus. This inflammatory, non-neoplastic tumor-like condition, presents as chronic sinusitis with periorbital edema, malar swelling and tenderness. Radiologic examination reveals total destruction of the bony walls of the nose, of the orbital rim and floor and of the maxillary sinus. The importance of recognizing this lesion lies in its benign nature but destructive capabilities. The destruction may possibly be accounted for by its anatomical origin in the septate sinus. Repeated surgical intervention may also serve to predispose or potentiate development of these lesions. Its resolution after adequate surgical extirpation and its place in the differential diagnosis of antral lesions are worthy of emphasis.

A destructive maxillary cemento-ossifying fibroma following maxillofacial trauma.

The cemento-ossifying fibroma, a mesodermal type of non-odontogenic tumor, is rarely discussed in the otolaryngologic literature. It is a tumor that is seen more in blacks than in whites, appears largely in the elderly, is chiefly located in the mandibular molar or premolar area and is generally neither aggressive nor excessively destructive. The triggering mechanism for its derivation from aberrant periodontal membrane growth or development from endosteal fibrous tissue remains controversial. We report a case of cemento-ossifying fibroma in a 26-year-old Hispanic male which was located in the posterior portion of the maxilla which destroyed the maxillary bone, orbital floor, and the lateral wall of the nose. One year prior to discovery of the lesion the patient sustained severe facial trauma resulting in facial bone fractures. It may be speculated that the trauma sustained was the critical triggering factor allowing for unchecked growth and destruction associated with an otherwise non-aggressive tumor, which may have been present prior to the traumatic incident.

Efficacy of DHE photodynamic therapy for respiratory papillomatosis: immediate and long-term results.

OBJECTIVES/HYPOTHESIS: Recurrent respiratory papillomatosis is a potentially life-threatening disease that affects both children and adults and can result in complete respiratory obstruction. Conventional therapies cannot prevent multiple recurrences. The authors have been evaluating photodynamic therapy (PDT) to treat this disease since 1988. This study compared the efficacy of PDT with dihematoporphyrinether (DHE) with traditional therapy. STUDY DESIGN: This was a randomized prospective trial of DHE-PDT. Patients were randomly assigned to receive one of two doses of DHE--3.25 mg/kg or 4.25 mg/kg body weight. They were compared with a concurrent control group. Disease extent was evaluated by direct laryngoscopy before treatment and over a 1-year period following treatment. Results were also compared with two historical cohorts of patients treated with lower doses of DHE. METHODS: Eighty-one patients, ages 4 to 74 years, with moderate to severe recurrent disease were enrolled. Forty-eight received PDT and 33 in the control group were treated with conventional therapy. Both PDT groups received 50 J laser light to activate the drug. Patients received an intravenous infusion of DHE as outpatients 48 to 72 hours before treatment. During direct laryngoscopy, light (630 nm) was delivered by an argon-pumped dye laser. Tissue biopsies were analyzed for presence of human papillomavirus (HPV). RESULTS: There was notable improvement with either drug dose over the first year. Those receiving 4.25 mg/kg DHE experienced a significantly larger decrease in papilloma growth rate. Three-year follow-up of a subset of patients confirmed that improvement was maintained. There was no impact of DHE-PDT on persistence of HPV DNA. CONCLUSION: This therapy holds promise for the treatment of laryngeal papillomas.

Vocal cord polyps: biochemical and histologic evaluation.

The stratified squamous epithelium covering vocal cord polyps can vary from normal to hyperplastic and keratinized. We have analyzed the histology and cytokeratins of 11 of these polyps. Cytokeratins were separated on one-dimensional SDS-acrylamide gels to determine molecular weights. There was significant heterogeneity in the cytokeratins present in the different polyps. Comparison of histologic findings and cytokeratin content showed a correlation between extent of keratinization and presence of high molecular weight cytokeratins. We conclude that the epithelium of vocal cord polyps exhibit patterns of cytokeratins characteristic of both hyperproliferation and abnormal states of differentiation, which are mirrored by histologic variations, and that vocal cord polyps are a heterogeneous group of benign lesions.

Association of papillomavirus with cancers of the head and neck.

One hundred one squamous cell carcinomas (SCC) (study group) and 116 tissues without SCC or papilloma from matched anatomic sites (control group) were evaluated for the presence of human papillomavirus (HPV) DNA. Squamous cell carcinomas of the tongue (18%), tonsil (29%), and pharynx (13%) specifically harbored HPV-16-related sequences. In contrast, the nose, mouth, and esophagus proved completely negative. In the larynx, a low prevalence of HPV-11/16-related DNA was found in both cancers (5%) and control tissues (4%), suggesting that the associations lacked specificity. Our results indicate that anatomic site plays a role in determining the susceptibility to infection, and that the clinical entities with which HPV infections are associated include both subclinical infection with no history of papilloma, and malignant disease.

The clinical treatment of laryngeal papillomas with hematoporphyrin therapy.

Photodynamic activation of hematoporphyrin derivative was originally developed for the treatment of cancer. This article demonstrates that it may also be an effective therapy for papillomavirus infections of the larynx. Seventy-two hours prior to surgery, hematoporphyrin derivative (6 mg/kg) was given intravenously to two patients with the adult-onset form of this disease. Three days later, endoscopic surgery was performed and 32 J/cm2 was delivered to the endolarynx via an argon pump dye laser with a red light output of 630 nm. No significant complications such as swelling or hemorrhage occurred. At follow-up (13 months) there has been no recurrence of the laryngeal papilloma in either of these patients. The surgical technique, molecular biology, and clinical implications of this work to control laryngeal papillomatosis are described.